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'  medica'l  books 

57'69.  E.  59th  St.,  >J . Y. 


SADNDERS' QUESTIOH-GOIPENDS. 


OPINIONS  OF  THE  PRESS. 

Extract  from  London  Lancet,  July  6tli,  1889. 

"  Useful  Adjuncts  to  Systematic  Reading.— It  is  fortunate  for  the  Student  that 
these  books  should  be  undertaken^Dy  cou^jjetent  hands,  by  men  who,  being  them- 
selves engaged  in  teaching,  know  where  the  subjects  require  most  elucidation,  and 
who^-hioreover,  are  careful  to  be  accurate  in  their  statementss" 

Extract  from  Nashville  Journal  of  Medicine  and  Surgery, 
December,  1889. 

MoERis'  Materia  Medica. — ^A  most  excellent  vade  mecum  for  students;  its 
arrangement  in  Questions  and  Answers  is  a  decided  advantage." 

From  Collage  and  Clinical  Eecord,  September,  1*89. 

Semple's  Pathology  and  Morbid  Anatomy.— "A  small  work  upon  Pathology 
and  Morbid  Anatomy,  that  reduces  such  complex  subjects  to  the  ready  comprehension 
of  the  student  and  practitioner,  is  a  very  acceptable  addition  to  medical  literature.  All 
the  more  modern  topics,  such  as  Bacteria  and  Bacilli,  and  the  most  recent  views  as  to 
Frinary  Pathology,  find  a  pla<;e  here,  and  in  the  hands  of  a  writer  and  teacher  skilled 
in  the  art  of  simplifying  abstruse  and  difficult  subjects  foi*  easy  comprehension,  are 
rendered  thoroughly  intelligible.  Few  physicians  do  more  than  refer  to  the  more 
elaborate  woi-ks  for  passing  information  at  the  time  it  is  absolutely  needed,  but  a  book 
like  this  of  Dr.  Semple's  can  be  taken  up  and  perused  continuously  to  the  profit  and 
instruction  of  the  reader." 

Extract  from  Buffalo  Medical  and  Surgical  Journal,  January,  1890. 

Morris'  Materia  Medica.— -"  Presented  in  a  unique  and  attractive  shape,  and 
cannot  fail  to  impress  the  mind  in  a  lasting  manner.  It  is  a  fine  specimen  of  book 
art." 

Extract  from  Cleveland  Medical  Gazette,  December,  1889. 

Hare's  Physiology. — "One  of  the  best  works  on  the  subject  that  has  come  under 
our  notice;  of  great  help  to  the  eai-nest  student.     Such  books  are  ever  valuable,-' 

Extract  from  Southern  California  Practitioner,  March,  1889. 

Ashton's  Obstetrics. — "  Dr.  Ashton's  little  work  is  a  marvel  of  condensation  and 
completeness.  It  will  be  of  unquestionable  value  to  the  practitioner  in  serving  to 
recall  some  of  the  multitudinous  facts  in  the  obstetrical  art,  which  will  frequently 
escape  the  most  capacious  memory." 

Extract  from  Southern  Clinic,  January,  1890. 

Morris'  Materia  Medica.— '^  The  arrangement  and  subject-matter  of  this  book 
leaves -nothing  to  be  asked  for,  either  for  the  student  or  medical  practitioner.  It  is  a 
valuable  substitute  for  larger  and  more  expensive  works." 


SADNDERS'  QUEST|ON-GOMPENDS. 

OPINIONS  OF  THE  PRESS. 

Extracts  from  Annals  of  Surgery,  June,  1889. 

'*  They  may  be  used  to  no  little  advantage  by  the  practitioner,  in  presenting  the- 
main  factrf  of  his  professional  work,  in  a  suitable  form  for  ready  reference  and  com- 
plete classification.  The  form  of  Questions  and  Answers  is  peculiarly  quajified.  tu 
secure  definiteness  of  information.  Dr.  Nancrede  has  given  us  a  woi'k  far  more  exten- 
sive in  Its  character  than  anything  of  the  kind. 

The  Medical  Student  who  shall  have  mastered  its  contents,  will,  eertainly  have 
acquired  all  the  essential  jwints  of  Anatomy." 

"The  Essentials  of  Physiology  are  most  clearly  and  comprehensively  outlined  by 
Dr.  Hare." 

Wolff's  Chemistry. — "The  questions  are  distinctly  .stated,  and  the  answers^ 
framed  with  marked  clearness,  are  fully  up  to  the  times."  ~  .  - :    • 

"Martin's  Surgery,  comprehensive  in  scope:  it  is  an  unusually  satisfactory  con- 
densation," 

Ashton's  Obstetrics. — "The  book  presents  all  the  essentials  of  its  subjects,  and 
much  other  valuable  matter." 

Extracts  from  University  Medical  Magazine. 

Martin's  Surgery. — "The  mo,st  pronounced  opponent  of  the  system  of '  Quizzing' 
in  vogue  at  the  present  day,  could  find  no  ground  for -objections  to  this  excellent  little 
book,  which  cleverly  combines  all  the  merits  of  condensation,  while  avoiding  the  errors 
of  superficiality  and  inaccuracy  with  which  such  Compends  commonly  iibound.  It  is  a 
pleasure  to  be  able  to  recommend  the  book  absolutely  and  without  reservation,  as  thor- 
oughly fulfilling  the  purpose  for  which  it  was  written,  and,  so  far  as  Surgery  is  con- 
r-"rned,  decidedly  the  best  of  its  kind  with  which  we  are  acquainted." 

Nancrede's  Anatomy. — "To  learn  Anatomy  is  not  merely  to  remember  the  names 
of  muscles,  arteries  and  nerves,  but  to  study  their  origin  and  insertions,  their  course 
and  relations,  and  their  distribution.  Dr.  Nancrede  has  kept  this  necessity  constantly 
in  mind,  and  the  student  who  masters  the  details  of  this  little  book  in  connection  with 
conscientious  work  in  the  dissecting  room,  will  find  it  a  help  for  which  his  tired  mem- 
ory will  often  sincerely  give  thanks.  The'questions  have  been  wisely  selected,  the 
answers  are  accurate  and  concisely  constructed,  but  still  with,  sufiicient  detail  to  free 
them  from  the  criticism  that  they  are  merely  lists  of  names." 

Extract  from  New  York  Medical  Record,  May,  1889. 

^'  Saunders'  Series  of  Student's  Manuals,  arranged  in  the  forni  of  Questions  and 
Answers,  are  concise,  without  the  omission  of  any  essential  facts.  Handsome  binding, 
good  paper  and  clear  type  increase  their  attractiveness." 

Extract  from  St.  Joseph's  Medical  Herald,  March,  1889. 

"Wolff's  Chemistry.— A  little  book  that  explains,  clearly  and  simply,,  the  most 
difficult  points  in  Medical  Chemistry,  so  that  this  need  no  longer  be  the  great  bugbear 
of  a  medical  student's  efforts." 


PRICE:  Cloth,  SI.OO;     Interfeaved,  for  Taking  Notes,  $1.25. 

Saunders'  Question-Compends. 

Arranged  in,  the  form  of  Questions  and  Answers, 

THHE  ADVANTAGE  OF  QUESTIONS  AND  ANSWERS.-vThe  usefulness  of  arranging  the 
A  Butijects  in  the  form  of  questions  and  answers,  will  be  apparent,  since  the  student,  in  reading 
the  standard  works,  often  is  at  a  loss  to  discoTer  the  important  points  to  be  remembered,  and  is 
equally  puzzled  when  he  attempts  to  formulate  ideas  as  to  the  manner  in  which  the  questions  could 
he  piii  iyi  the  examination-room.. 

No.  I. — Essentials  of  Physiology,  second  Edition.  Revised  and 
greatly  enlarged.  By  H.  A.  Haee.  M.D.,  Demonstrator  of  Therapeutics  and  Instructor 
in  Physical  Diagnosis  in  the  Medical  Department,  and  Instructor  in  Physiology  in  the  Biological 
Department,  of  the  University  of  Pennsylvania,  etc,  etc.     y 

No.  2.— Essentials  of  Surgery,  containing  also,  Surgical  Landmarks,  Minor  and 
Operative  Surgery,  and  a  Complete  Description,  together  with  full  Illustration  of  the  Hdndkerchief  and 
Rotter  Bandage.  Second  Edition,  with  ninety  Illustrations.  By  Edwabd 
Martin,  M.D.,  Instructor  in  Operative  Surgery  and  Lecturer  on  Minor  Surgery,  University^  of 
Pennsylvania;  Surgeon  to  the  Out- Patients'  Department  of  the  Children's  Hospital,  and  Surgical 
Registrar  of  the  Philadelphia  Hospital,  etc.,  etc.  - 

No.  3. —  Essentials  of  Anatomy,  including  Ffscera/ .4raa<oniy,BASEDUPON  the  last 
EDITION  OF  Grat.  Sccond  Edition.  Over  three  hundred  and  fifty  pages,  with  one  hun- 
dred and  seventeen  Illustrations,  By  Chas.  B.  Nancbede,  M.D.,  Professor  of  Surgery  and 
Clinical  Surgery  in  the  University  of  Michigan,  Ann  Arbor;  Corresponding  Member  of  the 
Eoyal  Academy  of  Medicine,  Rome,  Italy ;  Late  Surgeon  Jefferson  Medical  College,  etc.,  etc. 

No.  4. — Essentials  of  Medical  Chemistry,  organic  and  inorganic,  containing 
also  Questions  on  Medical  Physics,  Chemical  Physiology,  Analytical  Processes,  Urinalysis  and 
Toxicology.  By  Lawrence  Wolff,  M.D.,  Demonstrator  of  Chemistry,  Jefferson  Medical  College ; 
Visiting  PhysiciatL  to  German  Hospital  of  Philadelphia;  Member  of  Philadelphia  College  of 
Pharmacy,  etc.,  etc.  - 

No.  5.— Essentials  of  Obstetrics,  illustrated.  By  W.  Easteklt  A8HT0N,  M.D., 
Demonstrator  of  Clinical  Obstetrics  in  the  Jefferson  Medical  College,  and  Chief  of  Clinics  for 
Diseases  of  Women  in  the  Jefferson  Medical  Hospital,  etc.,  etc. 

No.  6.— Essentials  of  Pathology  and  IVIorbid  Anatomy,  illustrated.  By  c. 

E.  Armand  Semple,  B.A.,  M.B.  Cantab.,  L.S.A.,  M.R.C.P.  Lond.,  Physician  to  the  Northeastern 
Hospital  for  Children,  Hackney;  Professor  of  Vocal  and  Aural  Physiology  and  Examiner  in 
Acoustics  at  Trihitj' College,  London,  etc.,  etc. 

No.  7.— Essentials  of  Materia  Medica,  Therapeutics  and  Prescription 

Writing.  By  Heney  Mokris,M.D.,  late  Demonstrator,  Jefferson  Medical  College;  Fellow 
College  of  Physicians,  Philadelphia;  Co-Editor  Riddle's  Materia  Medica;  Visiting  Physician  to 
St.  Joseph's  Hospital,  etc.,  etc. 

Nos.  8  and  9. — Essentials  of  Practice  of  Medicine.   (Double  number,  over 

five  hundred  pages.)  By  Henry  Morris,  M.D.  With  an  Appendix  on  Urinary  Analysis  by 
Lawrence  Wolff,  M.D.    Profusely  Illustrated.    (In  preparation.) 

No.  10.— Essentials  of  Gynaecology,  with  numerous  niustrations.  ByEowiNB. 

Craigin,  M.D.,  Attending  Gynaecologist, Roosevelt  Hospital,  Out- Patients'  Department;  Assistant 
Surgeon,  New  York  Cancer  Hospital,  etc.,  etc. 

No.  II. — Essentials  of  Diseases  of  the  Skin,   illustrated.  By  Henry  w.  Stel- 

WAGON,  M.D.,  Physician  to  Philadelphia  Dispensary  for  Skin  Diseases;  Chief  «f  the  Skin  Dispen- 
sary in  the  Hospital  of  University  of  Pennsylvania ;  Physician  to  Skin  Department  oC  the  Howard 
Hospital;  Lecturer  on  Dermatology  in  the  Women's  Medical  College,  Philadelphia,  etc.,  etc. 

No.  12. — Essentials  of  Minor  Surgery  and  Bandaging,   with  an  Appendix 

on  Veiiereal  Diseases.  Illustrated.  By  Edward  Martin,  M.D,,  author  of  the  "Essen- 
tials of  Surgery,"  etc.    (In  preparation ) 

No.  13.— Essentials  of  Forensic  Medicine.   Profusely  niustrated.  By  armand 

Semple,  M.D.,  author  of  "  Essentials  of  Pathology  and  IVIorbid  Anatomy."    (In  preparation.) 

No.  14.— Essentials  of  the  Refraction  and  the  Diseases  of  the  Eye.  iiius- 

trated.  By  Edward  Jackson,  A.M.,  M.D.,  Professor  of  Diseases  of  the  Eye  in  the  Philadelphia 
Polj'clinic  and  College  for  Graduates  in  Medicine;  Member  of  the  American  Ophthalmological 
Society;  Fellow  of  the  College  of  Physicians  of  Philadelphia;  Fellow  of  the  American  Academy 
of  Medicine,  etc.,  etc.;  and  Essential  DiscaSCS  of  the  Nose  and  Throat.  lUustrated. 
By  E.  Baldwin  Gleason,  S.  B.,  M.D.,  Assistant  in  the  Nose  and  Throat  Dispensary  of  the  Hospital 
of  the  University  of  Pennsylvania;  Assistant  in  the  Nose  and  Throat  Department  of  the  Union 
Dispensary;  Member  of  the  German  Medical  Society,  Philadelphia  Polyclinic  Medical  Society, 
etc.,  etc.     (In  preparation.) 


SYLLABUS 


OF  THE 


OBSTETRICAL  LECTURES 


IN   THE 


MEDICAL  DEPARTMENT  OF  THE  UNIVERSITY 
OF  PENNSYLVANIA.  , 


BY 


RICHARD  C.  NORRIS,  A.M.,  M.D., 

DEMONSTRATOR    OF    OBSTETRICS,    UNIVERSITY    OF     PENNSYLVANIA. 


PHILADELPHIA: 

W.    B.    SAUNDERS, 

913  Walnut  Street. 
London:   IIknhy  Rknsiiaw.     Melbourne:   Geohge  Robertson  &  Co. 

1890. 


ISO' 


Entered  according  to  Act  of  Congress,  in  the  year  1890,  by 

W.   B.   SAUNDEES, 

In  the  Office  of  the  Librarian  of  Congress,  at  Washington,  D.  C. 


PRESS  OF   WM.    F.    FELL   &    CO. 

1220-24  SANSOM  STREET, 

PHILADELPHIA. 


r- 


ALFRED  M.HELLMAAJ 


^^^^^^ 


DEDICATED 

TO 


The  Medical  Class  of  the  University 
OF  Pennsylvania. 


PREFACE. 


K 


With  the  approval  of  Professor  Hirst  this  syllabus  has  been  pre- 
pared to  meet  the  difficulty  of  accurate  note-taking,  which  most 
medical  students  encounter.  The  subject  matter  has  been  so  an-anged 
that  uninterrupted  attendance  upon  lectures  is  essential  to  a  full 
knowledge  of  the  course.  The  design  of  the  book,  therefore,  is  to 
secure  for  the  student  a  logical  and  consecutive  outline  of  his  work, 
and  to  aid  him  in  classifying  the  knowledge  he  acquires  in  the  lecture 
room.  The  author  desires  to  express  his  indebtedness  to  Professor 
Hirst  for  many  suggestions  and  his  kindly  interest  in  the  preparation 
of  the  work,  and  to  indulge  the  hope  that  the  medical  class  may  find 
the  book  of  some  service  to  them. 

1234  Speuce  Steeet,  Philadelphia, 
December^  1889, 


CONTENTS. 


PART  I. 

PAGK 

MeistSteuation 17 

Ovulation 18 

iNSEMIJSrATION 20 

Feetilization 20 

The  Amnion 25 

The  Choeion 27 

The  Umbilical  Coed 28 

The  Decidu^ 29 

The  Placenta 31 

Physiology  of  the  Matuee  Fcetus 33 

Circulation 33 

Excretions 33 

Multiple  Impregnation 33 

Super-iinpreguation 34 

Diseases  of  the  Fcetus  in  Uteeo ,  35 

Deformities  and  Monstrosities ...  35 

Infectious  Diseases 37 

Diseases  of  Skin,  Brain,  Serous  Membranes,  Heart,  Connec- 
tive  Tissue,    Tumors,    Rachitis,    Anasarca,    Fractures, 

Anchyloses,  Luxations,  Amputations,  External  Violence  37 

Materjial  Conditions  affecting  Foetus 38 

Foetal  Death,  signs  of,  changes  in  Foetus  after 38 

Syphilis . 39 

Habitual  Death  of  Foetus 40 

Physiology  of  the  Newboen  Infant 40 

Respiration 40 

Weight 41 

Digestion 41 

Excretions 41 

xi 


XU  CONTENTS. 

PAGE 

Temperature 41 

Eyesight 41 

Pulse 42 

Blood 42 

Liver 42 

Heart 42 

Cord 42 

Medico-Legal  Points 42 

Anatomical  Points 42 

Peematuee  Infants .  43 

Incubation  and  Gavage -  43 

Sclerema 43 

Management  of  Newboen  Infant 43 

Clothing 43 

Feeding 44 

Cleansing 47 

Airing 47 

Eesting  Place 47 

Injueies  to  Infant  Dueing  Laboe 47 

Brain 47 

Peripheral  Nerves 48 

Skull 48 

Scalp 48 

Face 48 

Neck  . 48 

Limbs 49 

Trunk    . .    .    ; 49 

Asphyxia  Neonatoeum 49 

Diseases  of  the  Newboen  Infant 51 

Diseases  of  the  Lungs 51 

Syphilis 52 

Mastitis 53 

Specific  Fevers 53 

Congenital  Deformities 53 

Nasal  Catarrh 53 

Diseases  of  the  Mouth 53 

Diseases  of  the  Skin 54 

Ophthalmia  Neonatorum 54 

Hemophilia 55 


CONTENTS.  Xlll 

PAGE 

Icterus 55 

Cyanosis 55 

Diseases  of  the  Umbilicus 55 

Tetanus 56 

Melsena 56 

Intestinal  Perforation  and  Intussusception 56 

Bubl's  Disease 57 

Winckel's  Disease 57 

Sudden  Death  of  the  Infant 57 

Medication 57 

Pathology  of  the  Puerperal  State 57 

Abnormalities  of  Involution 57 

Puerperal  Anaemia 59 

Eepair  of  Injuries  after  Childbirth 59 

Puerperal  Hemorrhages 59 

Anomalies  of  the  Breasts 62 

Diseases  of  the  Urinary  Apparatus 63 

Diseases  of  the  Nervous  System 63 

Puerperal  Fever 63 

PART  II. 

Anatomy  of  the  Pelvis  Obstetrically  Considered  ...  69 

Deformities  of  the  Pelvis 72 

Pelvimetry 74 

fcetometry 76 

Antisepsis 77 

Diagnosis  of  Pregnancy 80 

Physiology  of  Pregnancy    . 83 

Pathology  of  Pregnancy 87 

Diseases  of  the  Genitalia 87 

Diseases  of  the  Alimentary  Canal 90 

Diseases  of  the  Urinary  Apparatus 92 

Diseases  of  the  Nervous  System 95 

Diseases  of  the  Circulatory  Apj)aratus 98 

Diseases  of  the  Respiratory  Apparatus 99 

Infectious  Diseases 100 

Diseases  of  the  Skin 101 

Injuries  and  Accidents 101 

Surgical  Operations  ...'.' 102 


XIV  CONTENTS. 

PAGE 

Abortion,  Miscarriage,  Premature  Labor 102 

Extrauterine  Pregnancy 105 

Labor 110 

Physiology 110 

Management 212 

PUERPEEIUM 114 

Physiology 114 

Management  .  .    .    .  , 117 

Mechaxism  of  Labor 119 

Obstetrical  Operations 131 

Induction  of  Premature  Labor  and  Abortion 131 

Forceps 132 

Version 135 

Embryotomy 137 

Symphyseotomy 138 

Csesarean  Section 138 

Laparo-elytrotomy 140 

Laparo-cystectomy 141 

Dystocia 141 

Anomalies  in  Expulsive  Force 141 

Excessive  Uterine  Action 141 

Uterine  Inertia 142 

Anomalies  in  Force  of  Eesistance 143 

Maternal  Obstructions 143 

Labor  in  Deformed  Pelvis 143 

Congenital  Anomalies  of  Development  in  the  Genital 

Canal 143 

Closure  and  Contraction  of  the  Cervix 144 

Closure  and  Contraction  of  the  Vagina  or  Vulvae  .  144 

Uterine  Displacements 144 

Tumors  of  the  Genital  Canal 144 

Tumors  of  Neighboring  Organs 144 

Fcetal  Obstructions 144 

Overgrowth 144 

Malformations  and  Tumors 144 

Diseases 144 

Mal-presentations  and  Positions 144 

Multiple  Births 145 

Abnormalities  in  the  Foetal  Appendages 145 


CONTENTS.  XV 

I'AGE 

Dystocia  due  to  Accident  to  Child  or  Mother 145 

Prolapse  of  Cord 145 

Placenta  Prsevia 146 

Accidental  Hemorrhage 146 

Post-partum  Hemorrhage 147 

Hemorrhage  from  Injuries 148 

Eupture  of  Uterus 148 

Eupture  of  Pelvic  Joints 149 

Diastasis  of  Eecti  Muscles 149 

Dystocia  due  to  Disease 149 

Puerperal  Convulsions 149 

Shock 151 

Typhoid,  Pneumonia  and  other  Adynamic  Diseases    .    .  151 

Valvular  Heart  Disease 151 

Sudden  Death 151 

Appendix 153 

Selection  of  Wet  Nurse 153 

Artificial  Feeding 153 


SYLLABUS  OF  OBSTETRIC  LECTURES. 


LECTURES   TO   GRADUATING  CLASS. 


PART   I. 
Menstruation. 

Definition. — A  periodic  discharge  of  a  sanguineous  fluid  from  the 
uterus  and  Fallopian  tubes,  occurring  during  the  time  of  a  woman's 
sexual  activity,  from  puberty  to  the  menopause. 

Time  of  Occurrence. — In  temperate  climates,  in  Teutonic  and 
Anglo-Saxon  girls,  the  first  menstniation  occurs  oftenest  in  the 
fifteenth  year.  It  is  influenced  by  {a)  Race,  (6)  Mode  of  Life,  (c) 
Climate,  (d)  Heredity,  (e)  Genital  Sense. 

Time  of  Cessation. — Usually  in  the  45th  year. 

Plienomeyia. 

1.  Congestion. — Manifested  in  changes  in  uterine  body,  mucous 
membrane,  adnexa  and  peritoneum. 

2.  Molimina. — The  clinical  and  sul3Jective  manifestations,  as  ner- 
vous irritability,  pigmentation,  enlargement  of  thyroid,  changes  in 
voice  and  circulation,  etc. 

3.  Rise  of  Temperature. — 0.5°  C. 

4.  Character  of  Flow. — Alkaline  and  composed  of  blood,  shreds 
of  mucous  membrane,  vaginal  and  uterine  secretion.  Is  darker  than 
ordinary  blood  and  should  not  clot. 

5.  Duration  of  Flow. — The  average  is  three  days. 

6.  Quantity.— Four  to  six  ounces. 
Theories  in  explanation  of  its  occurrence. 
1.    Why  it  occurs : — 

{a)  Cleansing.     Plethora.     The  ancients'  idea. 
2  17 


18  OBSTETRICAL  LECTURES. 

(b)  Pfliiger's.  The  ripening  of  the  ovule  within  the  ovary  and  the 
development  of  the  Graafian  follicle,  producing  a  nervous  irritation 
culminating  at  the  end  of  the  menstrual  month,  which  leads  to 
congestion  and  other  menstrual  phenomena. 

(c)  Result  of  the  death  and  degeneration  of  the  ovule.  If  the 
ovule  happens  to  be  impregnated,  menstruation  is  prevented.  If 
conception  has  not  occurred,  the  congested  condition  of  the  mucous 
membrane,  prepared  to  receive  and  surround  the  ovule,  results  in 
the  menstrual  discharge. 

(d)  Comparative  anatomy  and  physiology.  Explained  by  simi- 
larity to  heat  or  rut. 

(e)  In  obedience  to  a  central  nervous  influence  reflected  through 
the  sympathetic  nervous  system  to  the  ovaries  and  uterus. 

2.   Hotv  it  occurs : — 

(a)  Kundrat,  Engelmann,  Williams  :  By  fatty  degeneration  of 
the  mucous  membrane. 

(b)  Leopold  :  By  diapedesis. 

Connection  Between  Ovidation  and  Menstruation.  —From  Leo- 
pold's investigations  upon  29  pairs  of  ovaries,  examined  at  varying 
inteiTals  after  the  menstrual  period,  it  appears  that  menstruation 
and  ovulation  may  occur  independently — i.  e. ,  neither  are  dependent 
upon  the  other,  but  both  have  a  common  cause. 


Ovulation. 

The  Ovary. — Weight,  5.5  grms.  or  78  grains.  Diameters,  38x19 
xl3  mm.  or  l|x|xj  inches.  Constituent  parts  : — stroma,  glandular 
substan'je,  epithelial  covering,  blood  vessels,  lymphatics  and  nerves. 
The  epithelial  covering  of  the  ovary  difi"ers  from  the  epithelium 
lining  the  rest  of  the  peritoneal  surface,  in  that  it  is  columnar  and 
has  a  special  function  in  the  formation  of  the  ovum. 

Development  of  Graafian  Follicle. — The  specialized  columnar 
epithelium  covering  the  ovaiy  dips  down  into  the  ovarian  substance, 
forming  "egg-cords,"  and  carries  highly  specialized  cells.  A  con- 
striction occurs  above  and  below  one  of  these  specialized  cells  and 
the  follicle  thus  formed  is  an  immature  Grraafian  follicle,  containing 
an  immature  ovum.  These  follicles  at  first  lie  under  the  capsule  of 
the  ovary,  but  later  are  deeper  in  the  ovarian  structure. 


OVULATION.  19 

Anatomy  of  Fully  Developed  Graafian  Follidp. — From  vdthout 
inward. — 1.  Theca  folliculi,  composed  of  tunica  fibrosa  and  tunica 
propria.  2.  Membrana  granulosa.  3.  Di.scus  proligems,  surround- 
ing the  ovule.     4.   Liquor  folliculi. 

Anatomy  of  Ovum. — From  without  invxird. — 1.  Vitelline  mem- 
brane. 2.  Zona  pellucida.  3.  Internal  cell  membrane  ;  these  three 
comprising  the  cell  icall.  4.  Yelk,  or  cell  contents.  5.  Germinal 
vesicle,  or  nucleus.     6.  Germinal  spot,  or  nucleolus. 

Maturation  of  the  Ovum  and  Preparation  for  its  Impregnation. 

1st  stage.     Karyokinesis.     Amphi-aster  stage. 

2d  stage.     Extrusion  of  two  polar  globules. 

3d  stage.     The  female  pronucleus. 

Discharge  of  Mature  Ovum.  (Ovulation). — Theoriesto  account  for 
its  occurrence. 

1.  Sexual  congress. 

2.  Periodicity. 

3.  Congestion — increasing  the  amount  of  liquor  folliculi. 

4.  Influence  of  sympathetic  nervous  system. 

Mechanism  of  Escape  of  the  Ovule. — ^Tunica  propria  fails  at  the 
part  nearest  surface  of  ovary  (called  stigma)  ;  tunica  fibrosa  also 
gives  way  after  a  time,  from  pressure  of  the  Hquor  follicuh,  which 
increases  in  amount  as  a  result  of  the  liquefaction  of  the  cells  of  the 
membrana  granulosa.  At  this  weakened  spot  (stigma)  the  ovule 
and  discus  proligerus  are  situated,  and  they  escape  together  when 
the  tunica  fibrosa  raptures. 

Mechanism  of  Transmission  to  Tubes  and  Uterus. — The  ciliated 
epithelium  in  the  tubes,  by  their  lashing  movement,  start  a  cuiTcnt 
in  the  moisture  always  present  on  the  peritoneal  surface  toward  the 
uterus. 

Time  of  Occurrence. — Usually  at  the  height  of  the  menstraal  con- 
gestion.    Intermenstrual  ovulation  is,  however,  not  infrequent. 

The  Formation  of  the  Corpus  Luteum. — When  the  tunica  propria 
raptures,  and  the  ovum  escapes,  the  follicle  fills  with  blood  (the 
hematinof  the  extravasated  blood  giving  rise  to  the  "  yellow  "  color). 
The  membrana  granulosa  then  enlarges  by  active  multiplication  of 
its  cells  and  projects  into  the  cavity  of  the  follicle  in  ray -like  folds. 
Shrinking  and  cicatrization  occur,  causing  the  permanent  pits  or 
depressions  which  mark  the  surface  of  the  adult  ovary.     The  corpus 


20  OBSTETRICAL  LECTURES. 

luteum  spurium,  or  better  named,  that  ofmenstniation,  reaches  the 
highest  period  of  development  in  from  ten  to  thirty  days.  The 
corpus  luteum  verum,  or  better,  of  pregnancy,  is  simply  an  exaggera- 
tion or  farther  development  of  the  corpus  luteum  of  menstruation, 
the  greater  growth  due  to  the  increased  blood  supply  to  the  whole 
genital  apparatus.  It  grows  for  thirty  or  forty  days  after  con- 
ception, then  remains  stationary  until  after  the  fourth  mouth,  when 
it  begins  to  atrophy.  At  term  it  is  only  two-thirds  its  largest  size. 
One  month  after  delivery  it  is  reduced  to  a  small  mass  of  fibrous 
tissue. 

Insemination  and  Fertilization. 

Insemination. — The  deposition  of  seminal  fluid  within  the  genital 
tract  of  a  female  during  sexual  congress. 

Seminal  Fluid. — A  yellowish-white,  opaque,  sticky  fluid,  varying 
in  quantity  at  each  emission  from  one-fourth  to  two  drachms, 
possessing  a  very  peculiar  odor,  and  neutral  or  alkaline  in  reaction. 

Constituent  Parts : — 

{a)  Chemical  examination  :  Water,  82  per  cent. ;  salts,  mainly 
phosphates,  2  per  cent. ;  proteine  matter,  fats,  spermatin. 

(b)  Microscopical  examination  :  Crystals  of  phosphates,  sperma- 
tozoa, 

Filtration  shows  active  constituents  to  be  the  spermatic  particles. 

Abnormalities  of  Spermatic  Fluid : — 

[a)  Aspermatism,  when  no  discharge  of  fluid  occurs.  May  be 
congenital,  acquired  or  relative.  Acquired  when  resulting  from 
gonon'hoea,  prostatic  cibscess,  tuberculosis,  neurosis.  It  is  said  to  be 
relative  when  the  discharge  does  not  occur  at  the  desired  time. 
This  variety  may  be  due  to  fear  (neurosis)  or  sexual  excess. 

(6)  Polyspermism — excessive  quantity  of  fluid. 

(c)  Abnormalities  in  color  :  Red  when  tinged  with  blood  from  the 
mucous  membrane  ;  yellow,  with  pus  (gonorrhoea)  ;  violet,  from  the 
presence  of  indigo,  in  consequence  of  excessive  venery ;  green, 
when  to  this  last  there  is  added  gonorrhoeal  discharge,  and  beer 
color,  when  jaundice  is  present. 

{d)  Oligospermism — quantity  deficient. 

(e)  Azobspermism.  The  particles  dead  when  emitted,  or  alto- 
gether absent  fi-om  the  fluid.     A  physiological  absence  is  the  rule 


INSEMINATION  AND  FERTILIZATION.  21 

before  puberty  and  in  old  age.  Gronorrhoea  is  most  frequently  the 
cause  of  acquired  azoospermism.    Chronic  alcoholism  may  produce  it. 

Characteristics  of  the  Spermatic  Particle : — 

(a)  Length, -5-^  inch. 

[h)  Motility:  Its  own  length  in  one  second.  Hj^men  to  cervix 
in  3  hours  (Marion  Sims).  An  inch  in  7J  minutes  (Henle).  Can 
push  aside  eiDithelial  cells  ten  times  their  size. 

(c)  Vitality  or  longevity  :  Are  destroyed  by  heat,  cold,  acid 
solutions,  mineral  poisons,  by  lack  of  water.  In  some  cases,  as 
result  of  chronic  disease  or  alcoholic  or  sexual  excesses,  they  may  be 
dead  when  emitted.  Solution  of  bichloride  of  mercurj^,  1  to  10,000, 
will  destroy  them.  Under  some  circumstances  their  vitality  is  remark- 
able. They  have  been  found  alive  in  criminals  three  days  dead,  in 
a  bull  six  days  dead,  in  a  cow  six  days  after  insemination.  They 
remain  alive  for  months  in  the  bat,  for  three  years  in  the  queen  bee, 
and  in  the  living  female  have  been  found  in  the  cervix  eight  days 
after  copulation. 

Origin  : — 

(a)  Of  indifferent  constituents:  Cowper's  glands,  prostate,  vesicu- 
lae  seminales. 

(6)  Of  seminal  particles  :  By  a  process  similai:  to  that  in  the 
female,  the  spermatoblasts  undergo  the  changes  of  huryohinesis  and 
extmsion  of  the  seminal  globule,  the  spermatic  particles  thus 
remaining.  Theii-  first  appearance  in  the  fluid  is  at  the  fifteenth  or 
sixteenth  year. 

Mechanism  of  I^ection  or  Emission. — Muscular  contraction  emp- 
ties the  vesiculae  seminales  and  accelerates  the  passage  of  semen 
along  the  urethra. 

Mechanism  of  its  Reception. — From  observations  on  the  lower 
animals,  confirmed  upon  the  human  being,  the  uterus,  during  the 
orgasm,  becomes  shorter  and  broader,  descends  into  the  vagina,  is 
softer,  and  the  os,  alternately  opening  and  closing,  is  observed  to 
have  a  suction  action,  which  draws  the  semen  within  the  uterus. 

Eocceptions. — When  the  orgasm  in  the  male  does  not  occur  simul- 
taneously with  that  of  the  female  the  alkaline  mucus  in  the  cei-vix 
protects  the  spermatic  particles  from  the  acid  vaginal  secretion,  and 
the  seminal  lake  bathing  the  cervix  allows  the  particles,  by  their 
locomotion,  to  enter  the  uterus.     In  cases  where  conception  has  fol- 


22  OBSTETRICAL  LECTURES. 

lowed  insemination  during  unconsciousness,  or  when  the  semen  has 
been  deposited  only  on  the  external  genitals,  the  reception  of  the 
particles  is  explained  by  their  wonderful  powers  of  locomotion. 

Time  at  which  Insemination  is  least  likely  to  he  followed  hy 
Fertilization. — Seventeenth  to  twenty-third  day  after  the  cessation 
of  menstruation.  It  is  most  likely  to  occur  the  first  day  after  men- 
struation. 

Meeting  Place  of  Particle  and  Ovule.  — The  general  opinion  is  that 
this  occurs  in  the  ampullae  of  the  tubes.  A  more  recent  theory  is  that 
it  takes  place  in  the  fundus  of  the  uterus,  for  the  following  reasons : 
By  the  movement  of  the  epithelial  cilia  in  the  tubes,  and  the  vermi- 
form movement  of  the  tubes  themselves,  the  ovule  is  carried  to  the 
fundus  in  three  days.  The  usual  discharge  of  the  ovule  is  at  the 
height  of  the  menstmal  flow  ;  and  as  fruitful  copulation  usually 
occurs  four  to  seven  days  after  menstruation,  the  ovule  has  at  this 
time  reached  the  fundus. 

Mechanism  of  Fertilization. 

{a)  Attraction  of  SperTnatic  Particles  Toward  Ovum.-. — The  male 
elements  of  some  plants,  as  ferns,  are  attracted  by  malic  acid,  which 
is  excreted  by  the  female  organs  of  these  plants.  Similarly  an 
excretion  of  the  ovule  or  discus  proligerus  is  thought  to  attract  the 
spermatozoa. 

Q))  Penetration  of  Ovidar  Coats  by  Spermatozoa. — It  is  probable 
that  normally  in  the  human  being  but  one  particle  penetrates  the 
cell  contents,  thus  preventing  the  development  of  twins,  monsters, 
etc.  After  its  entrance  the  particle  loses  its  tail,  thus  forming  the 
male  pronucleus. 

(c)  The  union  of  male  and  female  pronucleus. 

The  Ovide  is  now  fertilized  or  impregnated.,  and  the  subsequent 
changes  are  biiefly  as  follows : — 

1.  Segmentation  of  the  vitellus  or  yolk,  until  completely  sub- 
divided, when  a  mulberry-like  mass  is  formed,  called  the  muriform 
body.  The  outermost  of  these  spheres  resulting  from  the  cleavage 
are  called  epihlastic^  and  the  innermost,  hypoblastic  spheres. 

2.  The  epiblastic  spheres  arrange  themselves  in  a  layer  under 
the  wall  of  the  ovule,  thus  enclosing  the  hypoblastic  spheres,  except 
at  one  point,  which  is  called  the  blastospore. 


INSEMINATION  AND   FERTILIZATION.  23 

3.  The  blastospore  closes. 

4.  A  fluid  forms  between  the  epiblastic  and  hypoblastic  spheres, 
and  the  latter  collect  in  a  mass  which  becomes  lens-shaped   and 
adheres  to  the  layer  of  epiblastic  spheres  at  the  site  of  the  blasto- 
spore.     The  fluid  accumulates  until  the  ovum  has  the  appearance  of 
a  thin-walled  vesicle,  which  is  called  the  blastodermic  vesicle. 

5.  Extension  of  the  hypoblastic  mass. 

6.  A  layer  of  cells  develops  between  the  epiblastic  and  hypo- 
blastic layers,  called  the  mesoblast,  the  blastoderm  now  consisting  of 
three  layers,  epiblast,  mesoblast  and  hypoblast. 

7.  A  central  thickening  of  the  hypoblast  forms  an  opaque  circular 
spot  on  the  blastoderm,  called  the  embryonic  area. 

8.  A  groove,  called  the  primitive  groove,  appears  in  the  embiyonic 

area. 

9.  By  an  arching-over  process  folds  springing  from  the  sides  of 
the  primitive  groove  {dorsal  plates)  join  to  form  the  spinal  canal, 
and  by  a  similar  process  folds  springing  from  the  base  of  the  dorsal 
plates  {ahdominal  plates)  enclose  the  abdominal  cavity.  The 
cephalic  and  caudal  extremities  are  formed  by  folds  rising  at  either 
end  of- the  groove. 

From  the  epiblast  is  developed  the  central  nervous  system,  super- 
ficial layer  of  skin,  the  organs  of  special  sense  ;  from  the  mesoblast, 
bone,   muscle,  connective  tissue,  blood  vessels  and  genito-urinaiy 

organs. 

From  the  hypoblast,  the  epithelium  of  the  respiratory  and  alimen- 

tray  tracts  and  glands. 

Development  of  Embryo  and  Foetus  in  the  Different  Months 

of  Pregnancy. 

First  J[fo?i«/i.— Indistinguishable  from  ovum  of  other  mammals. 
Is  a  flattened  vesicle.  The  embryo  is  nourished  by  yelk  sac  which, 
even  at  the  end  of  the  first  month,  is  larger  than  the  cephahc  ex- 
tremity of  the  foetus.  Visceral  arches  are  distinct.  Heart,  first 
traces  of  liver  and  kidneys,  eyes,  rudimentary  extremities,  oral  and 
anal  orifices  are  formed.  Spinal  canal  closes.  (Spina-bifida  results 
if  this  fails  to  occur  at  this  time.)     Length  1  cm.,  or  .4  inch. 


24  OBSTETRICAL  LECTURES. 

Second  Month. — Glrows  to  4  cm.  in  length,  and  is  about  the  size 
of  a  pigeon's  e,gg.  Visceral  clefts  close,  except  the  first,  which 
forms  the  external  auditoiy  meatus,  tympanum  and  Eustachian 
tube.  At  this  time  arrest  of  development  results  in  hare-lip,  umbil- 
ical hernia  or  exomj^halus.  Eyes,  nose  and  ears  are  distinguish- 
able. The  first  suggestion  of  hands  and  feet  appear,  webbed.  Ex- 
ternal genitals  also  now  develop,  but  sex  is  not  to  be  difieren- 
tiated. 

Third  3Ionth. — Maternal  blood  afibrds  nourishment ;  9  cm.  long 
and  about  size  of  goose  ^gg.  Fingers  and  toes  lose  their  webbed 
character  and  nails  appear  as  fine  membranes.  Points  of  ossifi- 
cation are  found  in  most  of  the  bones.  The  neck  separates  the 
head  from  the  tnink  and  sex  is  determined  by  the  appearance  of  the 
uteiiis.     Weight  30  grms.  =  460  grains. 

Fourth  Month. — 16  cm.  ^=  6  in.  in  length.  Lanugo  is  present. 
Intestines  contain  meconium.  Sex  is  well  defined.  Weight  55 
grms.  =  850  grains. 

Fifth  Month. — 25  cm.  =  10  in.  Yernix  caseosa  appears  in  places. 
The  face  is  senile  and  wrinkled.  Eyelids  begin  to  open.  Quicken- 
ing occurs.     Heart  sounds  are  heard.     Weight  273  grms.  =  8  oz. 

Sixth  Month. — 30  cm.  =  12  in.  Hair  grows  longer.  Eyebrows 
and  lashes  appear.  Testicles  apj^roach  inguinal  rings.  Weight  676 
grins.  =  23J  oz. 

Seventh  Month. — 35  cm.  =  14  in.  Pupillary  membrane  disap- 
pears.    Weight  1170  gnus.  =  41j  oz. 

Eighth  Month. — 40  cm.  =  1 6  in.  Down  on  the  face  begins  to  dis- 
appear. Left  testicle  has  descended.  Ossification  begins  in  lower 
epiphysis  of  femur.  Nails  do  not  project  beyond  finger-tips. 
Weight  1571  grms.  =  3 J  lbs. 

Ninth  Month. — 45  cm.  =18  in.  Subcutaneous  fat  increases.  Dia- 
meters of  the  head  about  1  to  H  cm.  less  than  at  term.  Weight 
1942  grms.  =  4 J  lbs. 

Mature  Foetus. — 50  cm.  long. "  Weight  7i  lbs.  Skin  is  rosy  ;  lanugo 
has  disappeared.  Nails  are  perfect  and  project  beyond  finger-tips. 
Ej'^es  are  opened.  The  centre  of  ossification  in  the  lower  epiphysis 
of  femur  is  5  mm.  in  diameter,  while  that  of  the  cuboid  bone  is 
just  beginning  to  show.     Diameters  of  head  are  normal. 


AMNION   AND   CHORION.  25 

Lengths  and  Weights  of  Frffus  : — 


1st  month, 

1  cm. 

.4  in. 

2d 

11 

4 

1.25 

3d 

1 1 

9 

3 

30  grms. 

460  grains. 

4tli 

'• 

16 

6 

55 

850       " 

5tli 

;( 

25 

10 

273 

8oz. 

6th 

1 1 

30 

12 

676 

23^  " 

7th 

ii. 

35 

14 

1170 

4H  " 

8th 

li 

40 

16 

1571 

3*  lbs. 

9th 

i( 

45 

18 

1942 

4i  '' 

10th 

u 

50 

21 

3250 

n " 

Amnion  and  Chorion. 

Amnion. 

Definition. — The  amnion  is  the.innermost  of  the  foetal  membranes, 
is  continuous  with  the  foetal  epidennis  at  the  umbilicus,  forming  a 
complete  sheath  for  the  umbilical  cord  and  forming  a  sac  or  bag  in 
which  the  foetus  is  enclosed. 

Development.— T\\Q  epiblast  extends  from  sides,  caudal  and 
cephalic  extremities  of  foetus,  and  curving  backward  approaches 
behind  same  until  the  reduplications  meet  and  thus  form  two  cavi- 
ties, the  True  and  the  False  Amniotic  Cavities.  The  True  contains 
the  liquor  amnii.  The  False,  the  yolk  sac  and  its  vessels,  which 
later  will  be  constituents  of  the  umbilical  cord. 

Anatomy. — Is  like  that  of  serous  membrane,  i.  e,,  a  layer  of  con- 
nective tissue  and  a  layer  of  endothelial  cells. 

Function. — Chiefly  to  secrete  the  liquor  amnii. 

Liquor  Amnii. 

Quantity. — One  to  two  pints  at  term. 

Specific  Gracity. — 1007. 

Composition. — Water,  albumen,  various  salts,  urea,  epithelium. 

Rpjiction.  — x^lkaline. 

Origin. — From  foetus,  mother,  and  from  both. 

i^imc^w??.— Distends  uterus  and  protects  foetus,  aifording  an  equal 
temperature  for  it  and  receiving  its  secretions.  Does  not  nourish 
beyond  adding  to  its  supply  of  water. 


26  obstetrical  lectures. 

Abnormalities  of  the  Amnion. 

Its  pathology  is  similar  to  tliat  of  all  serous  membranes,  i.  e. ,  in- 
flammation, exudations,  serous  and  plastic. 

(A)  Ahnomialities  of  Secretion  : — 

{a)  Oligohydr amnios. — Rare  ;  1  in  3000  or  4000  eases.  Is  dis- 
advantageous, because  walls  of  uterus  not  kept  apart  and  foetus  apt 
to  be  injured.  During  pregnancy  the  mother  is  likely  to  suffer  pain, 
and  labor  is  usually  difficult. 

(6)  Hydramnios. — When  two  quarts  or  more  of  fluid  may  be 
present.     Occurs  about  1  in  250  to  300  cases. 

Cause. — Production  may  be  increased  ;  absorption  may  be  de- 
creased. It  may  be  the  fault  of  foetus,  mother,  or  both.  On  the 
part  of  the  foetus  there  may  be  {a)  excess  of  urine  ;  (6)  excessive 
transudation  of  foetal  serum,  from  vessels  under  placental  surface, 
which  do  not  disappear  about  the  third  or  fourth  month  when 
hydramnios  exists,  or  from  any  condition  raising  the  blood  pressure 
in  the  umbilical  veins,  as  cirrhosis  of  the  liver  (syphilitic),  an 
abdominal  tumor,  or  any  abnormality  in  vascular  system  of  foetus, 
(c)  From  foetal  skin.  A  pathological  condition  of  this  is  found  in 
some  cases,  as  nsevi,  elephantiasis  congenita  cystica.  Having  its 
origin  in  the  mother,  the  hydramnios  maj^  be  a  part  of  a  general 
dropsy  or  be  due  to  an  exaggerated  hydraemia.  Very  rarely  does 
it  arise  fi"om  both  foetal  and  maternal  causes,  and  a  distinct  cause 
cannot  always  be  found.     It  is  most  frequently  of  foetal  origin. 

Diagnosis. — The  existence  of  pregnancy,  great  movability  of  the 
foetus,  and  the  distention  of  abdomen  greater  than  the  period  of 
duration  of  the  pregnancj^  would  account  for,  are  three  important 
signs.  When  there  is  a  very  large  amount  of  fluid  the  diagnosis  is 
very  difficult.  It  may  be  mistaken  for  ovarian  cyst,  ascites  accom- 
panying pregnancy,  distended  bladder  with  retroversion  of  gravid 
uterus. 

Classes. — Acute.  Rare.  There  is  a  sudden  transudation  of  fluid, 
from  some  traumatism.  Symptoins. — Pain,  difficulty  in  respiration, 
at  times  orthopnoea,  fever. 

Chronic. — Begins  at  the  third  or  fourth  month  and  steadily 
increases,  usually  causing  but  little  trouble. 

Treatment. — Immediate  evacuation  in  the  acute  variety ;  in  the 


AMNION   AND   CHORION.  27 

chronic  this  is,  as  a  rule,  not  required.  If  necessary,  the  Hfe  of 
foetus  is  not  to  be  considered,  as  it  will  usually  be  diseased.  Aspira- 
tion through  uterine  wall  condemned.  The  membranes  are  to  be 
punctured  at  the  os,  using  hand  as  plug  to  prevent  sudden  escape  of 
fluid. 

(B)  Plastic  Exudation. — Usually  occurs  early,  when  amnion  and 
fcetus  are  near  each  other,  and  thus  forms  bands  of  adhesion 
between  them,  and  even  causes  amputations  of  foetal  extremities 
and  premature  detachment  of  the  placenta. 

(C)  Abnormal  Tenuity. — Rare.  The  strings  thus  formed  may 
encircle  the  foetus. 

(D)  Cysts. — Of  no  clinical  importance. 

(E)  Rupture. — Abortion  maj^  result. 

The  Chorion. 

Definition. — The  chorion  is  the  outermost  of  the  foetal  membranes, 
and  is  formed  from  the  external  layer  of  the  non-germinal  epiblast. 
The  foetus  at  term  is  surrounded  by  three  membranes — the  deciduae, 
reflexa  and  vera  (derived  from  maternal  stnictures) ;  the  other  two, 
chorion  and  amnion,  from  foetal  structures.  The  chorion  is  the 
median  of  the  three  membranes. 

Development. — From  the  non-germinal  epiblast,  a  single  layer  of 
cells  springing  fi'om  the  outer  layer  of  the  blastodermic  membrane. 

Chorionic  Villi. — The  villi  of  the  chorion  are  hollow  at  first,  and 
are  comjjosed  of  an  external  epithelial  and  an  internal  mucoid  layer. 
Later  they  contain  blood  vessels.  Until  the  third  month  these  pro- 
jections into  the  maternal  tissue  abstract  nutriment,  oxygen,  etc., 
from  the  deciduae,  and  serve  to  keep  the  ovum  in  the  upper  portion 
of  the  uterus.  After  the  third  month  hypertrophy  of  one  portion 
takes  place  (chorion  frondosum)  to  form  the  placenta  ;  elsewhere  the 
villi  atrophy  (chorion  leve).  The  function  of  the  chorion  leve  is  to 
protect  the  integrity  of  the  ovum. 

Anomalies  of  the  Chorion. 

Placenta  Memhranacea. — The  normal  atrophy  of  a  portion  does 
not  occur,  and  placental  villi  are  developed  over  the  entire  surface 
of  the  chorion.     Such  placentae  are  thinner  than  the  normal. 


28  obstetrical  lectures. 

Diseases  of  the  Chorion. 

(a)  Cystic  Degeneration  of  the  Villi. — This  is  an  hypertrophy  and 
myxomatous  degeneration  of  the  villi  with  the  formation  of  cysts 
varying  in  size  from  that  of  a  millet  seed  to  a  hen's  egg.  The  old 
name  of  hydatidiform  mole  is  not  a  good  one,  as  mole  is  a  meaning- 
less term. 

Frequency. — 1  in  2000. 

Mortality. — Over  13  per  cent. 

Causes. — Diseases  of  endometrium,  or  uterine  wall ;  circulation  of 
villi  cut  off  by  absence  of  allantois  or  its  vessels. 

Symptoms. — Sudden  increase  in  size  of  uterus  at  third  or  fourth 
month  usually,  hemorrhage,  absence  of  foetus,  and  possibly  discharge 
of  cysts. 

Causes  of  Death. — Hemorrhage,  sepsis,  perforation  of  uterus. 

Treatment.  — Is  usually  incompatible  with  foetal  life.  Hemorrhage 
controlled  by  tampon.  If  diagnosed  early,  abortion  should  be  per- 
formed, as  it  assumes  sometimes  a  malignant  type  and  spreads  to 
uterine  wall,  and  thus  has  rarely  caused  fatal  hemonhage  and  sepsis. 
This  possible  thinning  of  the  uterine  wall  should  contraindicate  the 
use  of  curette  in  unskilled  hands. 

Q))  Fihro-myxomatous  Degeneration. — Up  to  the  present  time 
has  been  found  only  in  the  placental  portion. 

(c)   Chronic  inflammation. 

The  Umbilical  Cord. 

Development. — About  the  twentieth  day  after  conception  a  diver- 
ticulum from  the  caudal  portion  of  the  intestinal  canal  is  formed. 
It  becomes  constricted  a  short  distance  from  its  origin,  the  one  por- 
tion to  form  the  bladder ;  the  other  (larger)  leaves  the  abdominal 
cavity  with  the  omphalic  or  vitelline  duct,  and  as  an  elongated  cyst 
(allantois)  rapidlj^  grows  and  comes  in  contact  with  the  entire  chorion. 
Vessels  soon  develop,  two  arteries  and  two  veins,  which  communicate 
with  the  villi  of  the  chorion. 

One  of  these  veins  disappears  and  the  two  arteries  remain.  These 
three  vessels,  with  the  omphalic  duct,  the  remains  of  the  umbilical 
vesicle  and  the  pedicle  of  the  allantois  receive  a  covering  of  mucous 


THE   DECIDU^.  29 

tissue  (Wharton's  jelly)  and  a  layer  of  the  amnion,  and  compose  the 
umbilical  cord.  The  fully  developed  cord  at  term  is  20  to  2]  inches 
in  length,  ^  to  5-  inch  in  diameter,  containing  three  tortuous  vessels, 
one  vein  and  two  arteries,  which  possess  valves. 

Abnormalities  of  the  Cord. 

1.  Length. — It  may  be  very  short  (one  centimetre),  thus  pre- 
venting descent  of  the  foetus  or  giving  rise  to  hemorrhage  fi-om 
premature  detachment  of  the  placenta,  or  it  ma}'  be  very  long  (70 
inches)  and  be  found  coiled  around  the  foetus. 

2.  Torsion. — Eight  to  ten  twists  normal.  Due  to  twisting  of 
arteries  around  veins.  Usually  has  no  effect.  If  extreme  the  blood 
vessels  may  be  occluded.  G-reat  torsion  usually  occurs  after  the 
death  of  the  foetus. 

3.  Tlie  Vessels. — There  may  be  stenosis;  atheroma;  hypertrophy 
of  valves ;  an  overgrowth  of  connective  tissue  in  the  substance  of  the 
cord,  as  fi-om  syphilis  ;  varicosities. 

4.  Coils  and  Knots. — Loops  and  true  knots  may  be  formed,  which 
are  usually  not  tight.  Intrauterine  amputation,  not  due  to  these, 
but  to  the  formation  of  amniotic  bands.  The  cord  is  found  coiled 
around  the  neck,  about  once  in  every  foui"  cases. 

5.  Insertion. — (a)  Central  is  usual.  It  may  be  (6)  marginal,  or 
(c)  velamentous  (when  the  vessels  run  between  the  amnion  and 
chorion  before  entering  the  placenta),  or  (cZ)  meso-cord,  when  a 
fold  of  the  amnion  is  arranged  analogous  to  the  meso-rectum. 

6.  Hernia. — Due  to  aiTest  of  development  of  lateral  plates. 

7.  Cysts. — Due  to  liquefaction  of  the  mucous  tissue  in  the  cord, 
or  to  apoplexies  in  the  cord. 

8.  Calcareous  Deposits. — In  the  bloodvessels,  or  mucous  tissue. 
Are  often  associated  with  syphilis,  and  of  no  significance. 

The  umbilical  vesicle  is  the  sac  containing  the  nourishment  of  the 
embryo  until  the  development  of  the  chorion  and  placenta. 

The  Deciduae. 

Development. — After  the  ovum  is  impregnated  the  mucous  mem- 
brane of  the  uterus  hypertrophies  to  tenfold  its  normal  thickness, 
due  to   proliferation   of  young  connective   tissue   cells   above   the 


30  OBSTETRICAL  LECTURES. 

uterine  glands.  These  proliferated  cells  are  called  ' '  decidual  cells. ' ' 
The  ovum,  Ij^ing  in  the  folds  of  the  hypertrophied  mucosa,  finally  is 
completely  surrounded. 

That  portion  of  the  mucous  membrane  reflected  over  the  ovum 
is  the  deddua  rejiexa.  The  portion  under  the  ovum,  the  decidua 
serotma,  and  the  uterine  mucous  membrane  elsewhere,  the  decidua 

vera. 

Diseases, 

1.  Apoplexies. — These  are  a  common  cause  of  early  abortions,  and 
are  apt  to  occur  prior  to  the  second  or  third  month.  Causes. — 
Bright' s  disease,  repeated  congestions  from  frequent  coitus,  injuries, 
blows,  etc. 

2.  Inflammations.,  Chronic.  —  (a)  Hyperplastic  endometritis 
gravidarum.  The  hypertrophy  of  the  mucous  membrane  is  ex- 
aggerated, deflects  nourishment  to  itself  and  gives  rise  to  apoplexy 
and  early  abortion  of  a  fleshy  mass.  It  is  usually  the  result  of 
chronic  endometritis  prior  to  pregnancy,  {b)  Polypoid  endometritis 
gravidarum.  The  hypertrophy  confined  to  certain  areas.  Is  very 
rare.  Leads  to  abortion,  second  to  fourth  month,  (c)  Catarrhal 
endometritis  gravidarum.  There  is  an  abnormal  hypertrophy  of  the 
uterine  glands,  giving  rise  to  the  secretion  of  a  few  ounces  to  a  pint 
or  more,  with  periodic  discharges  of  thin  mucus,  called  hydror- 
rhoea  gravidarum,  {d)  Cystic  endometritis  gravidarum  occurs  very 
early.  The  glands  hypertrophy.  May  be  cured  by  subsequent 
growth  of  the  deciduae  or  may  continue  to  produce  hydrorrhoea 
gravidarum. 

3.  Inflammations.,  Acute,  (a)  Hemorrhagic  endometritis,  as 
occurs  in  cholera.  Causes  abortion,  (b)  Exanthematous  endome- 
tritis, the  exanthema  developing  on  the  uterine  mucous  membrane, 
as  on  other  mucous  membranes.  In  several  reported  cases  of 
measles  complicating  pregnancy,  abortion  has  occurred  about  the 
time  of  appearance  of  the  eruption,  (c)  Purulent  endometritis. 
Very  rare. 

4.  Atrophy. — May  afi"ect  either  of  the  deciduae.  Ill-developed 
placenta  may  result,  or  ovum  not  properly  held  in  place  may  drop 
and  develop  a  ' '  cervical  pregnancy. ' ' 


THE   PLACENTA.  31 


The  Placenta, 

(A)  Development. — At  the  tliii-d  month  the  chorion  vilH  atrophj^ 
except  at  the  decidua  serotina,  where  they  take  on  an  extraordinarj'- 
growth  to  form  the  placenta.  Each  villus  is  composed  of  connec- 
tive tissue  holding  capillar^' blood  vessels,  is  covered  with  epithelium, 
and  projecting  into  the  maternal  tissue  is  suiTOunded  by  a  capillaiy 
network  from  the  maternal  blood  vessels.  Later,  these  capillaiy  net- 
works disappear,  leaving  large  sinuses  or  lacunae,  which  receive  blood 
from  the  little  curling  arteries  rising  up  through  the  decidua  sero- 
tina and  into  which  the  villi  of  the  placenta  dip. 

{B)  The  Fully  Developed  Placenta. — At  term  the  placenta  weighs 
one  pound,  is  one  inch  thick  at  its  central  portion  and  seven  inches 
in  diameter.  The  foetal  side  is  covered  by  the  amnion  and  pene- 
trated by  the  cord.  The  maternal  surface  is  dark  red,  divided  by 
sulci  into  lobules  or  cotyledons  and  covered  with  a  grayish  trans- 
parent membrane  composed  of  the  cells  of  the  upper  layer  of  the 
decidua  serotina.  It  is  normally  situated  at  the  fundus,  anteriorly 
or  posteriorly. 

{C)  Functions. — It  absorbs  oxygen  and  nutriment,  acting  as  vica- 
rious lung  or  gill,  and  sei-ves  as  alimentary  tract,  kidney,  liver  and 
bowel. 

The  epithelium  of  the  villi,  in  carrying  on  these  ftmctions,  have  a 
selective  power.  Variola  germs  are  readily  absorbed,  tuberculosis 
very  rarely. 

Anomalies. 

(a)  Position — as  placenta  praevia. 

(b)  Size — as  placenta  membranacea. 

(c)  Shape — as  horse-shoe  placenta. 

{d)  Weight — may  be  above  or  below  normal. 

(e)  Number — as  placenta  duplex,  tripartita,  etc.  There  may  be 
accessor}^  growths,  as  placentae  succenturiatae,  placenta  spuria,  margi- 
nata,  etc. 

Diseases. 

{a)  (Edema. — Often  accompanies  hydramnion  and  macerated 
foetus  ;  stenosis  of  umbilical  vein  ;  general  effusions  in  the  mother. 
The  villi  may  be  normal. 


32  OBSTETRICAL  LECTURES. 

(h)   Degeneratwns : — 

1.  Cellular  Infiltration. — Occurs  in  syphilis.  Villi  are  distended 
with  granulation  cells,  blood  vessels  obliterated  and  foetal  life 
perishes. 

2.  Fihrous  and  Fatty  Degeneration  of  VilU. — Causes.  Any  ab- 
normality, accident  or  disease  of  placenta  abrogating  its  function,  as 
hemorrhage  from  the  placenta,  chronic  interstitial  placentitis,  diseases 
of  endometrium. 

Prognosis. — If  extensive,  foetus  dies.  If  small,  a  corresponding 
degree  of  ill-development  of  foetus.  Primary  fatty  change  only 
occurs  after  death  of  the  foetus. 

3.  Phthisical  Placenta. — An  exudate  from  villi  into  lacunae,  which 
undergoes  a  cheesj^  change. 

(4)  Calcareous. — Yeiy  common.  Occurs  in  indifferent  places  and 
has  no  effect  on  functions  of  the  placenta. 

(5)  3Ii/xo7nato2(s. — Similar  to  the  same  change  in  the  chorion.  Is 
usually  localized. 

(c)  Apople:des. — Very  common.    Are  a  frequent  cause  of  abortion. 

Causes. — Traumatism,  maternal  diseases  (especially  Bright' s 
disease),  foetal  diseases. 

{d)  Syphilis. — It  is  disputed  whether  there  be  a  distinct  form  of 
the  disease  in  the  placenta  which  offers  a  diagnosis  of  syphilis.    Prof. 
Hirst  inclines  to  the  belief  that  there  is  this  distinctive  form  of  pla- 
cental disease.     The  pathological  manifestations  differ  with  the  time 
of  infection,  as  follows  : — 

1 .  When  the  spermatic  particle  is  diseased  there  is  cellular  infil- 
tration of  villi. 

2.  When  the  mother  is  infected  during  fruitful  coitus,  there  is,  in 
addition  to  the  cell  infiltration,  an  overgrowth  of  connective  tissue 
over  the  cotyledons. 

3.  When  the  mother  is  infected  before  conception,  gummata 
appear  in  maternal  tissue. 

4.  When  the  mother  is  infected  after  conception,  the  placenta  is 
ordinarily  not  diseased  (Frankel). 

Prognosis. — For  foetus  :  the  cell  infiltration  destroys  the  blood  ves- 
sels and  foetal  life  perishes.  For  the  mother  :  not  indifferent.  From 
the  connective  tissue  development  adherent  placenta  likely  to  occur, 
increasing  the  risk  of  sepsis,  hemorrhage,  inversion  of  uterus,  etc. 


PHYSIOLOGY   OF   MATURE   FCETl'S.  'ii 

(e)  Acute  Placentitis. — Very  rare. 

(/)  Cysts. — Result  from  old  hemorrhages.  Are  never  large  and 
of  no  clinical  importance. 

(g)  Tumors. — 1.  Fibroid  change  or  Myxoma  Fibrosum;  2.  Local- 
ized Hypertrophies  ;  3.   Organized  Thromboses. 

Physiology  of  Mature  Fcetus. 

Foetal  Circulation. 

From  the  placenta  the  blood  passes  through  the  umbilical  vein  to 
under  surface  of  liver.  A  part  enters  the  liver  and  is  earned  to  the 
ascending  cava  by  the  hepatic  veins,  the  smaller  portion  passing 
direct  to  ascending  cava  through  the  ductus  venosus.  Joining  the 
blood  from  the  lower  extremities,  it  then  passes  to  the  right  auiicle, 
and  guided  by  the  Eustachian  valve  enters,  through  the  foramen 
ovale,  the  left  auiicle.  Thence  to  left  ventricle,  to  aorta,  the  greater 
part  being  carried  to  upper  extremities  and  head.  Returned  by  the 
descending  cava  to  the  right  auricle,  it  passes  to  the  right  ventricle, 
and  a  small  portion  being  carried  to  the  lungs  through  the  pulmonaiy 
arteiy,  the  remainder  reaches  the  aorta  through  the  ductus  arteriosus. 
From  the  aorta  it  passes  through  the  hypogastric  arteries,  to  the 
umbilical  arteries,  to  the  placenta,  a  small  portion  of  this  mixed 
blood  being  carried  by  the  aorta  into  the  lower  extremities. 

Foetal  Excretions. 

Bowels. — Inactive  during  intrauterine  life.  Meconium  is  dLs- 
charged  if  foetal  life  is  threatened,  as  by  an  apoplexy,  coiled  or  com- 
pressed cord,  etc.  If  it  occur  during  labor  should  always  be  a 
danger  signal. 

Bladder. — Is  evacuated  during  intrauterine  life  and  urine  is  always 
albuminous. 

If  foetus  has  lived  a  few  hours,  the  kidney  will  show  orange- 
colored  infarcts  of  urates,  which  are  of  medico-legal  value. 


Frequency. 


Multiple  Impregnation. 


Twins, 

1 

in 

89  births. 

Triplets, 

] 

I  ( 

7,900 

(( 

Quadniplets, 

,  1 

1 1 

3' 

ri,]26 

( I 

34  OBSTETRICAL  LECTURES. 

Two  cases  have  been  reported — one  in  Italy,  the  other  in  Texas — 
of  six  children  at  a  birth. 
Twins. — How  it  occurs  : — 

1.  Two  OTules  discharged  at  once  from  separate  Grraafian  follicles 
in  same  or  diJBFerent  ovaries. 

2.  Two  ovules  from  same  follicle. 

3.  Unioval,  i.  e. ,  from  a  single  ovule  two  foetuses  developed  by 
entrance  of  more  than  one  spermatic  particle,  or  by  a  division  of  the 
layers  of  the  early  formed  membrane.  Uniovar  twins  have  single 
placenta  and  chorion,  but  two  amnions;  otherwise  each  foetus  has  its 
own  placenta  and  chorion,  as  well  as  amnion. 

"  Prognosis. — Mother — Liability  is  greater  to  albuminuria  and 
eclampsia,  to  post-partum  hemorrhage  from  over-distention,  and 
labor  is  apt  to  be  long  and  difficult. 

Foetus. — Much  graver.  If  from  two  ovules  one  in  twenty-three 
born  dead ;  from  a  single  ovule  one  in  six. 

Reasons  for  gravity  of  prognosis  to  foetus  : — 

1.  Lack  of  room,  hence  ill-developed  ;  under  weight  and  size. 

2.  If  one  is  stronger  and  better  developed  it  attracts  more  nutriment, 
and  finally  crowds  and  compresses  its  fellow,  flattening  it  out  (Foetus 
Papyraceus) . 

3.  In  unioval  the  anastomoses  between  foetal  and  placental  vessels 
apt  to  produce  monsters. 

4.  Hydramnios  apt  to  occur. 

5.  Many  complications  at  birth. 

Super-Impregnation. 

{a)  Super  foetation. — The  product  of  conception  occupying  the 
utems  a  second  impregnation  follows  a  subsequent  coitus. 

(J))  Super-fecundation.. — Two  or  more  ovules  fecundated  at  or 
near  the  same  period  of  time. 

The  possibility  of  its  occurrence  after  a  long  inters^al  doubted,  since 
there  is  no  proof  of  ovulation  during  j^regnancy.  The  limit  is  within 
a  few  days. 

Determination  of  Sex. — At  birth  the  proportion  is  106  boys  to 
100  girls.     At  puberty  it  is  about  equal. 

Theories. — None  satisfactory.  The  parent  possessing  the  greater 
mental,  physical  and  sexual  development  may  have  some  influence. 


DISEASES   OF   THE  FCETUS   IN   UTERO.  35 

When  Determined. — Not  kuown.     Up  to  the  third  month  embryo 
has  equally  the  elements  of  both  sexes. 


Diseases  of  the  Fcetus  in  Utero. 

Mortality. — One-fourth  of  all  die  before  term. 

Deformities  and  Monstrosities. 

Every  departure  from  the  normal  is  classified  under  one  of  the 
following  : — 

1.  Hemiteratic. 

2.  Heterotaxic. 

3.  Hermaphroditic. 

4.  Monstrous. 

1.  Henilteratic,  semi-monster — ?'.e.,  an  approach  to  monstrosity — 
include  : — 

Anomalies  of  («)  growth  (as  dwarfs,  giants). 

"  (&)  volume  (as  microcephalic  head,  large  breast,  etc.). 

'•  (c)  forin  (as  deformity  of  pelvis). 

{d)  color  (as  albinism,  melanism,  mole,  etc.). 
(e)  s^nic^wre  (as  abnormal  ossification  of  cartilage), 
^y  (/)  displacement  of  splanchnic  organs  (as  hernia,  sj^ina 

bifida,  encephalocele). 
by  {9)  displacement  of  non-splanchnic  organs   (as  club- 
foot, scoliosis,  bow-legs), 
"by  Qi)  change  of  connection  (as  anomalous  attsichment  of 
muscles,  tendons,  nerves). 
Anomalous  [i)  openings  (as  patulous  foramen  ovale,  rectum  opening 
into  urethra). 
(./)  imperf orations  (as  rectum,  vagina,  oesophagus). 
{]{■)  union  of  organs  (as  horseshoe  kidney,  webbed  fingers). 
Anomalies  by  if)  disjunction  (as  hare-lip,  cleft-palate). 

{m)  numerical  diminution  (as  absence  of  one  or  more 

fingers). 
{n)  augmentation  (as  six  fingers,  three  testicles,   six 
toes). 

2.  Heterotaxic. — Anomalous  order,  reversal  of  natural  position  of 


36  OBSTETRICAL  LECTURES. 

organs,  as  liver  on  left  side,  pyloric  and  cardiac  ends  of  stomach 
reversed. 

3.  Hermaphrodism. — A  vicious  conformation  of  the  genital 
organs  comprising  elements  of  both  sexes.  When  called  upon  to 
make  the  diagnosis  always  exclude  an  ill-developed  male,  as  cleft 
scrotum,  or  rudimentary  penis.  By  this  error  males  have  been 
educated  as  females. 

4.  Monstrosities. — A  living  creature  so  much  deformed  as  to 
excite  wonder  or  disgust. 

{A)  Aiitositic  Monsters. — Those  capable  of  independent  existence. 
These  are  further  subdivided  and  etymologically  named  : — 

(a)  Ectromelic  (abort-limb).  Absence  of  upper  or  lower  extremity. 

(b)  Symelic  (union-limb).     Lower  limbs  fused. 

(c)  Celosomatic  (hernia-body).     Extreme  hernia. 

(d)  Exencephalic.    Brain  normal,  but  cranial  bones  not  developed. 

(e)  Pseudencephalic.  Bones  of  cranium  lacking  and  rudimentary 
brain. 

(/)  Anencephalic.     No  brain  and  no  development  of  cranium. 
(g)  Cyclocephalic.     The  two  eyes  fused.     Reversal  of  eyes  and 
nose  apt  to  occur  (rhinocephalic). 

(A)  Otocephalic.  The  two  ears  meet  under  chin,  and  lower  por- 
tion of  face  not  developed. 

(B)  Omphalositic. — Possessing  an  imperfect  kind  of  life,  which 
ceases  when  the  umbilical  cord  is  divided.  It  only  occurs  in  twin 
pregnancy,  the  intimate  anastomosis  of  vessels  in  unioval  sometimes 
allows  one  heart  a  preponderating  power,  and  the  other,  not  used, 
atrophies.     These  may  be 

(a)  Acardiac. 

(b)  Acephalic. 

(c)  Asomatic. 

(d)  Foetus  amorphous  or  anideous  (a  shapeless  mass  of  flesh). 

(C)  Composite  Monsters : — 

(a)  Double  autositic.  Named  by  the  portion  of  the  body  which 
unites  them,  as  xyphopagic  (joined  by  xyphoid),  synsomatic  (joined 
by  bodies),  syncepJialic  (joined  by  heads),  etc. 

(b)  Double  parasitic,  as  an  extra  pair  of  legs,  extra  child  hanging 
from  stomach,  etc. 

(c)  Triple  monsters.     Very  rare. 


DISEASES   OF  THE   FCETUS   IN   UTERO.  37 

Diseases  of  Foetus. 

Infectious — Causes. — Specifie  microorganisms  which  in  some  way 
pass  through  maternal  blood  to  foetus.  The  conclusion  from  many- 
conflicting  observations  is  that  this  is  not  invariable  but  possible. 
Several  theories  have  been  advanced  to  explain  how  the  microorgan- 
isms reach  the  foetus. 

The  following  are  some  of  the  diseases  in  which  the  specific  micro- 
organisms have  been  found  in  the  foetus  :  smallpox,  measles,  ery- 
sipelas, typhoid,  pneumonia,  cholera,  syphihs,  malaria,  anthrax. 
The  power  of  various  organisms  to  transmit  themselves  is  not  equal. 
Smallpox  very  apt  to  pass  ;  tuberculosis,  but  one  case  reported.  If 
foetus  not  inoculated,  abortion  apt  to  occur. 

Congenital  Skin  Diseases — as  ichthyosis. 

Intra-cranial  Disease — as  sclerosis  or  tumors  of  brain,  etc. 

Inflammation,  recent  or  old,  of  Serous  Membranes— ascites, 
hydrothorax,  hydrocephalus. 

Valvular  Diseases  of  Heart. 

Overgrowth  of  Connective  Tissue — in  intestines,  blood  ves- 
sels, liver,  etc.  (largely  due  to  syphilis). 

Tumors — as  distended  bladder,  congenital  goitre,  sacral  tumors, 
etc. 

Rachitis. — Signs  of  congenital  rachitis.  Head  square  and  bent 
to  one  side,  spine  tortuous,  joints  enlarged,  pigeon  breast,  curved 
long  bones. 

Anasarca — usually  due  to  obliteration  of  umbilical  or  placental 
circulation. 

Spontaneous  Fractures  of  the  Long  Bones — most  commonly 
due  to  rachitis,  and  then  apt  to  be  multiple. 

Anchyloses  and  Luxations. — Anchyloses  are  very  rare,  are  due 
to  inflammation  of  the  joint  membranes  and  seriously  prevent  nor- 
mal mechanism.  Luxations  are  rarely  intrauterine  but  frequently 
the  result  of  mismanaged  breech  and  arm  presentations  when  much 
force  is  used.  A  rigidity  of  th$  muscles  due  to  prolonged  pressure 
may  be  confounded  with  the  above. 

Intrauterine  Amputations — caused  by  amniotic  bands. 

External  Violence — of  medico-legal  interest. 


38  OBSTETRICAL  LECTURES. 

Maternal  Conditions  aiFecting*  Fostus : — 

1.  Nervous  Disturbance  in  the  Mother. — Maternal  impressions ; 
emotions  (sometimes  fatal). 

2.  Abnormalities  in  Temperature. — Foetus  not  necessarily  affected 
if  maternal  temperature  be  raised  sloidy  to  105°-107°.  It  will  be, 
however,  if  the  rise  be  sudden.     Always  fatal  at  109°. 

3.  Defective  Nutrition.  —  Serious  cbronic  diseases  producing 
anaemia  ;  pernicious  vomiting  of  pregnancy. 

Treatment. — Remove  cause.     Iron,  arsenic,  good  hygiene. 

4.  Diseases  of  the  Endometrium.^  the  Womb  and  its  Adnexa. — 
Usually  cause  abortion. 

5.  Alterations  in  the  Maternal  Blood  Pressure. — Fatal  to  embryos 
of  animals. 

6.  Poisons  in  the  Maternal  Blood.  —  The  infectious  diseases ; 
eclampsia  ;  saturnism  ;  bile  salts. 

7.  He7wlity. — A  predisposition  to  disease  acquired  in  utero. 

8.  Maternal  Death. — Foetus  has  been  found  alive  as  long  after 
death  of  mother  as  two  hours. 

Diagnosis  of  Foetal  Death  :— 

1.  Absence  of  heart  sounds. 

2.  Palpation  of  macerated  skull  (crepitus). 

3.  Temperature  in  cervix  (death  likely  if  not  1°  above  body  tem- 
perature). 

4.  Hand  in  utero  to  feel  for  heart  pulsation. 

5.  Peptonuria. 

6.  Cessation  of  growth  or  diminution  in  size  of  uterus. 

7.  Disturbances  of  renal  functions. 

8.  Disappearance  of  subjective  signs  of  pregnancy. 

9.  Appearance  of  milk  secretion. 

The  effects  of  foetal  death  upon  the  mother  are  practically  nothing 
so  long  as  the  membranes  are  unbroken. 

Changes  in  structure  of  Foetus  after  death. — May  be  any  of  the 
following  : — 

1.  Maceration. 

2.  Putrefaction  (only  after  membranes  are  broken). 

3.  Saponification. 

4.  Mummification. 

5.  Calcification. 

6.  Absorption  (before  third  month). 


DISEASES   OF   THE   FCETUS   IN   UTERO.  39 

Syphilis  of  Foetus. 
Infection  of  foetus  occurs  in  three  ways  : — 
J .  From  diseased  Ovule. 

2.  From  diseased  Spermatic  Particle. 

3.  From  Maternal  Blood. 

The  poison  can  also  pass  from  foetus  to  mother,  thus  explaining 
several  curious  phenomena,  as  the  appearance  of  secondary  symptoms 
in  the  mother  in  the  latter  months  of 'pregnancy. 

Mamfestations.—PTOteain  and  polymorphous,  as  in  the  adult.  There 
is  an  overgrowth  of  connective  tissue  in  all  parts  of  the  body. 

(a)  Skin. — Pemphigoid  eruption,  especially  on  soles  of  feet  and 
palms  of  hands. 

(6)  ^owes.— An  embryonal  tissue,  a  transition  stage  between  car- 
tilage and  bone,  by  a  premature  attempt  at  ossification,  is  not  suffi- 
ciently nourished,  dies  and  undergoes  a  fatty  change,  leaving  between 
diaphysis  and  epiphysis  of  all  the  long  bones  ?i  jagged  yelloic  line. 

(c)  Z^'yer.— Normally  is  ^  of  body  weight.  Syphilis  of  foetus 
shows  liver  much  increased  in  siz«  and  weight. 

{d)  >Sp?ef?i.— Normally  3^  of  body  weight.  Much  increased  in 
syphilis. 

(e)  Lungs. — One  of  three  conditions  found: — 

1.  Overgrowth  of  connective  tissue,  constituting  fibroid  pneumonia 
or  phthisis  (most  common). 

2.  Catan-hal  or  White  Pneumonia.  By  an  overgrowth  of  epithe- 
lium in  the  air  vesicles  the  lung  dies,  fatty  degeneration  follows, 
giving  the  lungs  a  dead- white  appearance,  with  imprint  of  ribs. 

3.  Gummata — rarest. 

Effect  of  SypJuh's  upon  Life  of  Foetus.— ''In  83  per  cent,  of  all 
foetal  deaths  the  parents  are  syphilitic.  In  657  pregnancies  in 
syphiHtic  women  35  per  cent,  ended  in  abortion,  and  a  large  number 
of  the  children  expelled  at  terai  were  stillborn  (Charpentier).  Of 
414  pregnant  women,  with  syphilis,  only  63  per  cent,  anived  at 
term." 

Diagnosis.— By  history  of  father  or  mother,  and  by  an  examina- 
tion of  skin,  long  bones,  liver,  spleen  and  lungs. 

Tre/am.ent.—^y\)\\\\\t\Q  patients  should  not  be  allowed  to  maiTy 
without  a  prolonged  course  of  treatment  (for  a  year),  to  be  followed 


40  OBSTETRICAL  LECTURES. 

by  a  mild  treatment  of  the  mother  throughout  pregnancy,  and  sexual 
intercourse  interdicted,  to  avoid  abortion  during  the  treatment.  The 
time  that  must  elapse  after  parents  are  affected  before  foetus  may  be 
expected  to  be  free  from  the  poison  varies.  In  one  case  after  twelve 
years  the  foetus  was  syphilitic.  If  the  mother  is  contaminated  at  the 
fruitful  coitus,  or  befVjre,  treatment  should  be  begun  at  once.  Both 
mercury  and  iodide  of  potash  can  pass  to  the  foetus  and  modify  its 
syphilitic  disease.  Chlorate  of  potash  (10-20  gr.,  t.  d.)  may  be  given 
in  any  disease  interfering  with  the  development  of  the  placenta,  to 
supply  oxygen,  as  recommended  by  Penrose,  Sir  J.  Y.  Simpson, 
Barker,  Bruce  and  others. 

Habitual  Death  of  Foetus. 

Causes  in  order  of  frequency  : — 

1.  Hyiildlu. — Eighty-three  per  cent,  of  all  foetal  deaths. 

2.  Metrltvi^  endometritis  and  uterine  displacements. 

3.  Alterations  in  maiernal  hlood.,  as  anaemia  or  plethora. 

4.  Chronic  diseases  of  the  mother. — Tuberculosis,  cancer,  malaria, 
nephritis,  diabetes. 

5.  Causes  resident  in  foetus.,  as  recurring  deformities. 

6.  Chronic  poisoning. — Saturnism.  Tobacco.  (In  the  Virginia 
factories  such  effects  not  noticed.) 

7.  Causes  referable  to  fcMher^  as  phthisis,  albuminuria,  chronic 
poisoning. 

8.  Ilahit  and  heredity. 

Treatment. — Ascertain  cause,  and  treat  that. 

Physiology  of  Newborn  Infant. 

Respiration. 

Two  factors  to  explain  its  establishment : — 

1.  Elxternal  irritation,  resulting  from  change  of  environment 
(from  liquid,  with  temperature  of  99°,  to  air,  with  temperature  of 
70°),  gives  rise  to  reflex  action  of  all  muscles. 

2.  Maternal  supply  of  oxygen  being  cut  off,  there  is  an  accumula- 
tion of  CO 2,  and  the  primary  action  of  this  is  stimulant  to  respira- 
tory apparatus. 

Bate  of  respiration  is  44,  sinking,  after  a  few  months,  to  35. 


PHYSIOLOGY   OF   NEWBORN  INFANT.  41 

Weight. 
7. 3  lbs.     There  is  a  gradual  increase,  about  one  and  a  half  pounds 
before  and  one  pound  after  the  fourth  month,  for  each  month. 


Month. 

Weight  K)s. 

Month. 

Weight 

1 

7.75 

7 

16 

2 

9.5 

8 

17 

3 

11 

9 

18 

4 

12.5 

10 

19 

5 

14 

11 

20 

6 

15 

12 

21 

Digestion. 

Accomplished  by  digestive  juices  except  pancreatic  and  saHvary 
secretion. 

Partially  dependent  upon  bacteria  in  stomach  and  intestines. 
Size  of  >SVomac/L— Knowledge  of  this  important  to  avoid  over- 
feeding. 

1st  week,  46  cub.  cent.        3d  month,  140  cub.  cent. 

2d       "  78        "  5th      "       260 

3d  and  4th  month,  85        "  9th      "       375 

Position  of  Stomach. —Ita  axis  is  almost  longitudinal,  which  ex- 
plains frequent  regurgitation  and  vomiting. 

Excretions. 

(a)  ^rme.— Always  albuminous  for  first  few  weeks.  Quantity 
has  never  been  estimated.  Voided  6-20  times  in  24  hours.  Does 
not  stain  diapers,  and  mistake  may  thus  be  made  of  supposing  none 
to  have  been  voided,  (b)  Bowels.— Meeoumm  for  the  first  48  hours. 
Later,  it  becomes  light  yellow,  is  not  formed,  is  sour  and  acid.  The 
normal  frequency  of  evacuation  is  four  times  in  24  hours. 

Temperature. 

Peculiarities  are  irregularity  and  height,  with  the  variations  above 
98°.     Slight  causes  will  produce  great  changes. 

Eyesight. 
Always  hypermetropic. 


42  OBSTETRICAL  LECTURES. 

Pulse. 

125-160,  as  shown  by  heart  sounds. 

Blood. 

Total  bulk  to  body  weight  8  per  cent.  ;  six  to  seven  millions  red 
blood  corpuscles  to  the  c.  c. ,  which  are  more  spherical  and  do  not 
tend  to  form  rouleaux.  Shadow  corpuscles  abundant.  White  blood 
corpuscles  more  numerous  than  in  adult. 

Liver. 

Blood  supply  diminished,  capillaries  distended,  secretion  of  bile 
lessened.  Lower  pressure  in  hepatic  veins.  Capsule  of  Glisson 
swollen. 

Heart. 

Exhibits  transition  from  foetal  to  infantile  circulation  by  closure  of 
foramen  ovale  and  obliteration  of  ductus  arteriosus. 

Cord. 

After  24  hours  line  of  demarcation  at  its  base.  Necrosis  of  am- 
niotic covering.  Mummification  of  mucous  tissue.  Destruction  of 
its  vessels.  Cord  drops  ofi"  about  4th  day,  followed  by  retraction  of 
granulating  button  within  the  umbilical  ring. 

Medico-Legal  Points. 

Difiicult  to  determine  whether  child  has  lived  or  whether  injuries 
on  its  body  have  been  inflicted  with  murderous  intent. 

Anatomical  Points. 

To  be  borne  in  mind  when  making  autopsies  to  determine  cause  of 
death  of  newborn  infant : — 

The  normal  size  of  thymus  gland^  the  relatively  large  heart. 
Lungs  should  be  inflated  and  overlap  heart.  Liver ^  jo  of  body 
weight.  Ductus  choledochus,  patulous.  The  sigmoid  and  appen- 
dix very  large  and  the  bladder  relatively  large. 


MANAGEMENT   OF   NEWBORN   INFANT.  4S 

Abnormalities  in  the  Physiology  of  Premature  Infants. 
The  two  main  deviations  are — 
(a)  Low  temperature — variations  below  98°. 
{b)  Inability  to  ingest  and  digest  food. 
Treatment. — Incubation  and  gavage. 
Mortality  of  this  Treatment : — 

At  6  months  22  per  cent,  saved. 

"  7  "  38 
"  8  "  89 
"  8J       "     95 

Sclerema. — A  disease  only  found  in  these  premature  infants. 
Occurs  most  often  in  lying-in  hospitals.  The  most  prominent 
symptom  is  a  hardening  of  the  skin,  beginning  in  the  legs  and" 
spreading,  usually  sparing  breasts  and  belly.  Jaundice  or  a  hemor- 
rhagic condition  usually  accompanies  it.  Temperature  is  very  low, 
95°.  Its  pathology  is  not  well  understood.  The  most  probable 
explanation  is  that  the  large  excess  of  palmitic  acid  in  infants 
solidifies  at  this  low  temperature.  The  condition  is  a  grave  one  and 
apt  to  be  fatal. 

Management  of  Newborn  Infant. 

Clothing". 

A  baby  should  be  clothed  in  winter  as  follows :   A  binder,  of 
flannel  or  knit  wool,  twice  around  stomach,  a  knit  shirt,  diaper, 
knit  shoes,  and  three  skirts,  the  first  flannel,  the  next  linen,  and 
finally  its  dress. 

The  baby  basket  should  contain  at  least — 

3  day  dresses, 

3  flannel  skirts, 

2  vests, 

4  pairs  of  shoes, 
1  hair  brush, 

19  diapers, 

3  binders, 

4  night  dresses. 


44  OBSTETRICAL  LECTURES. 

Feeding^. 

Human  Milk. — Secretion  established  at  the  end  of  forty-eight 
hours.  Derives  its  origin  from  an  overgrowth  of  epitheUal  cells 
lining  the  glands,  their  infiltration  with  fat  and  subsequent  rupture. 
Is  emulsified  by  casein.     Specific  gravity  1024-35. 

Chemical  Constitution  (A.  V.  Meigs). 

Human.  Cows'.  Cream. 

Water 87.163  87.012  79.122 

Fat 4.283  4.209  13.362 

Casein 1.046  3.252  2.919 

Sugar 7.407  5.000  4.140 

Ash 101  .527  .457 

Fat — Tests — {a)  Chemical. — 10  c.c.  milk,  20  c.c.  water,  and  20 
c.c.  ether;  agitate  violently  for  five  minutes;  add  20  c.c.  absolute 
alcohol,  agitate,  and  allow  to  stand.  Ethereal  and  alcoholic  solu- 
tion of  fat  rises.  The  residue  is  washed  with  ether,  the  solution 
of  fat  evaporated  on  hot-water  bath,  the  whole  quantity  of  fat  re- 
maining. 

(b)  Microscopical. — By  counting  the  number  of  fat  globules, 
800,000  to  the  cubic  millimetre  normal.     Not  reliable. 

Casein. — Nutritive  quality  depends  more  on  casein  than  fat.  The 
quantity  of  casein  varies  according  to  different  chemists.  From 
recent  investigations,  it  would  appear  that  there  are  three  groups  of 
albuminoid  bodies — one  coagulable  (casein),  two  others  non-cogula- 
ble.  The  diff"erence  between  the  casein  of  human  milk  and  cows' 
milk  is  not  as  yet  made  out.  This  difference  is  thought  to  explain 
the  difficulties  of  artificial  feeding. 

Sugar. — Is  lactose,  and  is  not  so  sweetening  as  cane  sugar. 

Quantity  in  Twenty -four  Hours. — At  the  end  of  the  seventh  day, 
14  ounces ;  at  the  end  of  fourth  week,  2  pints.  The  infant  after 
each  meal  gains  in  weight  from  3-6  ounces,  thus  showing  the  amount 
of  its  meal. 

Factors  Influencing  Secretion — {a)  Quality. — If  the  diet  of  the 
nursing  mother  contains  too  little  albuminous  food,  or  too  little  fat, 
the  milk  is  poor  in  fat.     If  it  contain  too  much  meat,  fat  or  malt 


MANAGEMENT   OF   NEWBORN   INFANT.  45 

liquor,  it  will  have  an  excess  of  fat,  which  the  infant  cannot  digest. 
The  proper  diet  does  not  differ  from  the  ordinary  diet.  An  addi- 
tional half  pint  of  milk  may  be  advised  to  be  taken  at  eleven  and 
four  o'clock. 

(b)  Quantity. — This  may  be  improved  by  the  addition  of  milk  as 
advised,  and  to  some  a  half  pint  of  malt  liquor  may  be  given  at 
dinner,  watching  its  effect  upon  the  child.  Always  see  that  the 
nurse  does  not  interfere  with  the  diet. 

Conditions  Interfering  with  the  Mammary  Function. — (a)  Atro- 
phy of  glandular  elements  and  overgroicth  of  connective  tissue.,  as 
from  ill-developed  physique,  pressure  of  corsets,  refusal  to  nurse, 
etc. 

(b)  Diseases. — Any  acute,  infectious  disease,  as  the  exanthemata, 
erysipelas,  diphtheria,  typhoid.  In  phthisis  the  quantity  is  not  often 
affected,  but  the  quality  is  impaired.  There  is  apt  to  be  less  fat  and 
casein,  and  the  milk  may  contain  the  tubercle  bacillus.  A  syphilitic 
mother  should  not  nurse  her  child,  for  fear  of  infecting  it,  if  it  be  not 
already  infected,  but  a  syphilitic  child  may  be  suckled  by  its  mother 
without  danger  of  her  infection  (Colles'  Law). 

(c)  Hemorrhage.,  as  when  much  blood  is  lost  during  the  puerpe- 
rium,  or  hy  the  early  return  of  menstraation,  etc. 

{d)  Emotions. — How  these  affect  the  milk  is  not  yet  explained, 
possibly  by  the  production  of  leucomaines.  When  the  mother  is 
influenced  by  profound  emotions,  her  milk  may  become  even  poison- 
ous to  her  child. 

If  mother  ainnot  nurse  child.,  it  should  he  fed — 

1.  By  wet  nurse,  and  the  selection  should  be  governed  by  the 
following  considerations : — 

{a)  She  should  have  milk  of  good  quality,  which  is  best  judged 
by  the  appearance  of  her  own  child. 

(b)  She  should  be  oi  suitable  age. 

(c)  Equable  disposition  and  absence  of  disagreeable  qualities. 
{d)  She  should  not  have  syphihs. 

2.  Artificial  feeding. 

Asses'  milk  is  much  more  like  human  milk  than  cows'  milk,  but 
as  it  is  not  conveniently  procurable,  the  latter  is  used.  Cows'  milk 
differs  from  human  milk  mainly  in  the  per  cent,  of  casein  and  sugar. 
Used  alone,  it  would  produce  indigestion,  diarrhoea,  etc.,  probably 


46  OBSTETRICAL  LECTURES. 

due  to  the  greater  proportion  of  casein,  and  to  reduce  this,  dilution 
is  resorted  to. 

Meigs   Formula  for  Artificial  Food. 
Milk,  one  tablespoonfal. 
Cream,  two  tablespoonfuls. 
Lime  water,  two  tablespoonfuls. 
Sugar  water,  three  tablespoonfuls. 

(The  sugar  water  is  prepared  by  dissolving  171  drachms  of  sugar 
of  milk  in  one  pint  of  water. ) 

By  an  analysis  of  this  formula  the  proportions  of  water,  fat, 
casein,  sugar  and  ash  are  practically  the  same  as  in  human  milk.  In 
this  formula,  however,  no  account  is  taken  of  the  non-coagulable 
albuminoids  recently  discovered,  hence  Prof.  Hirst  recommends  that 
one  drachm  of  Mellins'  food  be  added,  which  supplies  the  amount 
of  non-coagulable  albuminoids  (about  IJ  per  cent.)  required. 

Microorganisms  and  Ptomaines  in  Milk. — A  large  proportion  of 
artificially-fed  children  die  annually,  particularly  in  the  hot  summer 
months,  from  gastro-intestiual  disturbances  largely  due  to  the  con- 
tamination of  milk  by  various  microorganisms  and  ptomaines. 

Sterilized.  Milk. — To  avoid  and  destroy  such  poisons  the  milk  should 
be  sterilized.  Boiling  the  milk  makes  it  less  digestible  and  nutri- 
tious. Sterilizing  it  avoids  this  and  a  suitable  apparatus  or  ' '  steril- 
izer ' '  accomplishes  what  is  desired,  if  it  be  used  with  attention  to 
all  details  and  greatest  possible  care.  The  apparatus  devised  by 
Prof  Hirst  consists  of  an  ordinary  egg-holder,  containing  twelve  two- 
ounce  bottles,  suspended  in  a  tin  bucket.  Each  morning  the  bottles 
are  sterilized  by  baking  them  until  cotton  placed  in  their  mouths  is 
browned.  The  milk  and  cream  is  then  added,  the  bottles  lightly 
stoppered  with  sterilized  cotton  and  steamed  for  twenty  minutes, 
when  they  are  placed  in  a  refrigerator  until  used.  The  lime  water 
and  sugar  water  should  be  prepared  with  boiled  water  and  kept  air- 
tight. 

The  nursing  bottle  (Starr's)  and  nipple  should  be  scalded  after 
each  meal  and  kept  submerged.  The  infant  should  be  fed  every  two 
hours  during  the  day  and  twice  during  the  night  (at  11  and  5). 

Proprietary  Foods : — 

(a)  Milk  Foods.  — Dried  milk,  as  Nestle' s  or  Carnrick'  s.  Condensed 
milk — a  part  of  the  water  is  driven  off  by  evaporation,     Matzoon — 


PATHOLOGY   OF   NEWBORN   INFANT.  47 

is  similar  to  koumiss,  i  e.,  impregnated  with  CO  2.  All  of  these 
probably  have  their  digestibility  and  nutritive  value  partly  destroyed. 
Condensed  milk  apparently  does  not  disagree,  but  the  fat  which  it 
produces  in  the  child  is  from  the  excess  of  sugar  and  is  not  healthy 
nor  stable,  and  in  such  children  rachitis  may  develop. 

ih)  Liehig  Foods — are  digesting  or  semi-digested  foods,  as  Mel- 
lins',  etc. 

(c)  Farinaceous  Foods — as  Blair's  Wheat,  Hubbell's  Wheat, 
Imperial  Grranum,  Hood's  Food,  Ridge's  Food,  Robinson's  Patent 
Barley,  Bethlehem  Oat-meal,  etc.  These  are  never  to  be  used  before 
the  fourth  month,  as  the  pancreatic  and  mouth  secretions  of  the 
baby  cannot  convert  starch  into  sugar  before  that  time. 

Cleansing. 

Daily  bath  in  the  middle  of  the  day  in  the  warmest  part  of  the 
room.     Temperature  of  water  90°.     Castile  soap  and  soft  sponge. 

Airing. 

In  summer  the  baby  may  be  taken  out  after  the  second  month. 
In  winter  after  the  third  month,  for  a  few  minutes  about  noon, 
although  each  baby  is  a  law  unto  itself  in  this  respect. 

Resting  Place. 

Preferably  a  crib. 


Pathology  of  Newborn  Infant. 
INJURIES  TO  INFANT  DURING  LABOR. 

Classified  according  to  seat  of  injury. 

1.  Brain. 

The  injury  is  most  frequently  the  result  of  faulty  use  of  forceps 
or  extraction  of  after-coming  head.  It  may  be  («)  an  apoplexy, 
varying  in  extent  from  rupture  of  a  small  vessel  to  longitudinal  sinus. 
If  lesser  in  degree,  the  child  may  live  to  adult  age,  but  is  apt  to  have 
paralyses  or  mental  impairment,  {h)  The  brain  substance  may  be 
crushexl.  (c)  Injuries  not  so  grave,  but  affecting  intellectual  or 
X)hysical  centr&i. 


48  OBSTETRICAL  LECTURES. 

2.  Peripheral  Nerves. 

Facial  and  brachial  plexuses  most  frequently  damaged.  The 
majority  of  cases  of  facial  hemiplegia  due  to  above  use  of  for- 
ceps. Recovery  usually  in  the  course  of  a  week.  The  brachial 
palsies  result  from  unskilled  attempts  at  extracting  the  shoulders, 
and  are  more  likely  to  be  permanent. 

3.  Skull. 

(a)  Spoon-shaped  Depressions  of  Parietal  Bone. — A  prominent 
promontory  or  forceps  may  cause  them. 

(6)  Fracture.s. — Kequire  an  antiseptic  dressing, 
(c)  Distortion. — Very  common.     Hesult  of  diiferent  presentations 
and  positions.     Disappears  within  the  first  three  days. 

4.  Scalp. 

{a)  Caput  Succedaneum. — A  serous  infiltration  of  that  portion  of 
the  presenting  part  corresponding  to  external  os.  Disappears  in 
three  days  and  requires  no  treatment. 

(b)  CephaJo-hematomata. — A  more  dangerous  condition,  and  to 
be  distinguished  from  the  above.  Two  or  three  days  after  birth  a 
swelling  develops,  rapidly  increasing  in  size,  with  signs  of  a  cystic 
tumor,  distinctly  confined  to  boundary  of  one  of  the  cranial  bones. 
It  is  due  to  a  subpericranial  hemorrhage,  and  is  to  be-  treated  by 
non-interference,  except  when  suppuration  occurs.  It  then  should 
be  antiseptically  laid  open  and  drained. 

(c)  Contused  and  lacerated,  luounds. 

{d)  Sloughs. — The  vitality  of  the  scalp  may  be  destroyed  by  for- 
ceps, or  prolonged  pressure  and  sloughs  appear  in  a  few  days. 
Require  ordinary  surgical  treatment. 

5.  Face. 

Caput  succedaneum  may  form.  Ui/es  may  be  injured  by  careless 
examinations  or  extraction  of  after-corn ina:  head. 


b 


6.  Neck. 

(a)  Thrombus  of  muscles^  most  frequently  of  sterno-cleido-mastoid, 
with  the  development  of  torticollis. 
(5)  Fracture  or  decapitation. 


PATHOLOGY   OF   NEWBORN    INFANT.  49 

7.  Limbs. 

Fractures^  which  are  usually  a  separation  of  diaphysis  and  epiphy- 
sis, requiring  fixation  and  extension. 

8.  Trunk. 

Perforations  of  the  groin  may  occur,  as  result  of  use  of  blunt  hook 
or  forceps  applied  to  breech. 

ASPHYXIA. 

Asphyxia  of  the  newborn  child  results  in  consequence  of  an 
insufficient  supply  of  oxygen. 

Physiology  of  the  Institution  of  Respiration. — The  sudden  change 
in  its  environment  (liquid  99°  to  air  70°)  produces  an  exaggerated 
stimulation  of  all  muscles  to  reflex  action.  Placental  respiration  is 
abolished,  and  the  accumulated  CO 2  primarily  stimulates,  finally 
paralyzes  the  respiratory  centre. 

Causes : — 

{a)  Intrauterine. 

1.  Foetal  inspiration. 

2.  Any  interference  with  placental  respiration  paralyzing  the 
brain  centres,  as  premature  detachment  of  placenta  ;  coiling,  com- 
pression or  prolapse  of  the  cord  ;  diminution  of  the  calibre  of  the 
umbilical  vessels,  as  from  syphilitic  periphlebitis ;  excessive  and 
prolonged  uterine  contraction. 

3.  Prolonged  pressure  on  foetal  brain  by  pelvis  or  forceps,  para- 
lyzing brain  centres. 

4.  G-rave  systemic  diseases  of  the  mother,  including  hemorrhage, 
uterine  or  pulmonary. 

5.  Immature  development  of  the  infant. 

6.  Anomalies  or  diseases  of  the  foetus  preventing  the  entrance  of 
air  into  the  respiratory  tract,  or  preventing  the  proper  distribution 
of  blood  from  right  ventricle  to  lungs,  as  a  patulous  foramen  ovale 
or  atresia  of  the  pulmonary  artery. 

{h)  Extrauterine. 

1.  Placing  the  infant  after  birth  in  a   position  unfavorable  for 
respiration. 
4 


50  OBSTETRICAL  LECTURES. 

2.  Precipitate  labor. 

3.  Interference  with  the  access  of  air  to  respii'atory,  passages,  as 
by  a  caul,  unruptured  membranes,  or  maternal  discharges. 

Varieties : — 

(a)  Livida.  Accumulation  of  CO2  is  excessive,  yet  circulation 
and  reflexes  are  preserved. 

(6)  Pallida.  Usually  an  advanced  stage  of  the  former,  character- 
ized \}j  weakness  of  the  heart  and  slowing  of  its  pulsations  to  a 
marked  degree  and  abolition  of  reflexes. 

Treatment. — If  possible,  should  be  prevented  by  removing  the 
cause. 

1.  Extraction  of  mucus  from  throat  and  fauces  by  holding  the 
child  by  the  feet  and  cleaning  the  mouth  with  finger, 

2.  Application  of  an  exaggerated  stimulus,  as  slapping,  rubbing, 
immersing  in  warm  water  and  pouring  ice  water  on  epigastrium  ; 
electricity,  if  at  hand,  preferably  faradic,  the  poles  being  placed  on 
epigastrium  and  at  the  root  of  the  neck.  In  the  pallid  variety  only 
the  most  powerful  of  these  are  useful. 

3.  Artificial  respiration. 

(a)  Sylvester' s  method.     (Not  recommended.) 

(6)  Marshall  Hall's,  modified  to  suit  the  requirements  of  the  new- 
bom  infant  by  suspending  in  a  towel,  and  thus  rolling  it  from  side  to 
side. 

(c)  Schultze's.     (Probably  the  best. ) 

{d)  Mouth-to-mouth  insufflation. 

(e)  Catheterization  of  larynx  with  soft  catheter. 

(/)  As  a  last  resort  tracheotomy  and  catheterization  through  the 
wound.     Only  required  in  most  exceptional  cases. 

Risks  Attending  Artificial  Respiration. — Injuries,  as  apoplexies  ; 
Schultze's  method  may  injure  the  spine;  hemorrhagic  effusions  in 
the  pleurae  and  lungs ;  rupture  of  the  air  vesicles  in  insufflation ; 
trachea  and  larynx  may  be  injured. 


PATHOLOGY   OF   NEWBORN   INFANT.  51 

DISEASES  OF  THE  NEWBORN  INFANT. 

I.  Diseases  of  the  Lungs. 
1.  Atelectasis.     2.   Pneumonia.     3.  Tuberculosis. 

1.  Atelectasis. 
Cause. — Not  known. 

Diagnosis. — Dullness  on  percussion  on  one  side.  Respiration 
slightly  accelerated  and  imperfect.  Absence  of  fever.  These  signs 
present  at  birth. 

Pathological  Anatomy. — One  lung  is  found  shriveled  up,  is  not 
crepitant  and  sinks  when  placed  in  water. 

Prognosis. — Not  grave. 

Treatment. — Grentle  inflation  of  lung  with  catheter. 

2.  Pneimionia. — {a)  Syphilitic,     {b)  Inspiration. 

(a)  Syphilitic. — The  diagnosis  can  be  made  by  a  histoiy  of 
syphilis  in  the  parents,  by  the  signs  of  foetal  syphilis  together  with 
the  cyanosis  and  physical  signs  of  pneumonia.  Treatment  is  of  no 
avail,  the  child  usually  dying  within  24  hours. 

Pathological  Anatomy. — An  enormous  overgrowth  of  connective 
tissue  is  found,  compressing  the  blood  vessels  and  diminishing  the 
capacity  of  the  air  vesicles.  As  some  air  has  entered  the  lung,  a 
cut-off  portion  never  sinks,  but  does  not  float  buoyantly. 

(Jj)  Inspiixition  Pneumonia. — May  be  due  to  inspiration  of  mater- 
nal discharges,  food,  or  septic  matter. 

Maternal  Discharges. — Pneumonia  arising  from  this  cause  devel- 
ops twenty-four  hours  after  birth,  in  a  child  apparently  healthy,  the 
temperature  at  this  time  beginning  to  rise  and  respirations  growing 
more  rapid.  The  child  is  restless,  refuses  nipple,  is  cyanotic,  at 
times  gasps  for  breath,  and  there  is  dullness  over  one  or  both  lungs. 

Prognosis.  — Grave. 

Treatment. — J  to  1  gr.  carbonate  of  ammonium  every  four  hours. 
Cotton  jacket.  Turpentine  stupes  twice  a  day.  Mother's  milk,  from 
medicine  dropper,  eveiy  hour,  and  with  this  a  few  drops  of  brandy 
every  three  or  four  hours. 

Pathological  Anatomy. — Shows  the  features  of  catarrhal  pneu- 
monia. A  cut-off  portion  always  sinks  (thus  distinguished  from 
syphilitic).  The  cause  of  pneumonia  resulting  from  inspiration  of 
food  not  yet  made  out.     It  may  occur  any  time  after  birth. 


52  OBSTETRICAL  LECTURES. 

Septic  variety  is  rare  since  introduction  of  antisepsis. 

3.    Tuherculosis. — Rare. 

Caused  by  mouth-to-mouth  respiration  by  a  tuberculous  person. 

Differential  Diagnosis. 
Atelectasis.  Inspii^ation  Pneumonia. 

One  lung  affected.  Usually  both. 

Exists  at  birth.  After  twenty-four  hours. 

Temperature  not  elevated.  Always  elevated. 

II.  Syphilis  in  Newborn  Infant. 

Symptoms. — ^The  child  is  often  ill-developed  and  ill-nurtured,  but 
the  characteristic  signs  do  not  usually  develop  before  four  to  six 
weeks.     In  order  of  frequency  these  signs  are — 

Coryza  syphilitica. 

Maculo-papular  syphilide. 

Roseola. 

Cutaneous  papules  and  mucous  tubercles. 

Rhagades  oris  et  ani. 

Pemphigus. 

Cutaneous  ulcers. 

Paronychias. 

Pseudo-paralyses  of  extremities. 

Hemorrhagic  diathesis. 

Bone  diseases. 

Fever. 

Disease  of  testicles. 
Treatment. — Best  results  from  internal  use  of  calomel  with  chalk 
or  soda,  ^^  grain  given  twice  a  day,  gradually  increasing  the  dose. 
Should  vomiting  or  diarrhoea  occur,  resort  to  inunction,  rubbing  a 
piece  of  mercurial  ointment  as  large  as  end  of  finger  on  binder  every 
other  day.     Always  carefully  watch  for  poisoning. 

This  treatment  should  be  kept  up  for  months,  replacing  it  from 
time  to  time  by  tonics  or  drop  doses  of  the  syrup  ferri  iodidi. 

Prognosis, — If  the  child  is  well  nourished  by  its  mother  or  wet 
nurse  the  prognosis  is  very  good,  so  long  as  some  important  internal 
organ  is  not  seriously  affected.  In  artificially  fed  children  it  is  very 
bad. 


PATHOLOGY  OF  NEWBORN  INFANT.  53 

III.  Mastitis. 

Four  days  after  birtli  the  breasts  in  both  sexes  contain  colostrum, 
which  has  disappeared  by  the  twentieth  day.  During  this  period 
there  may  occur  in  the  breast  of  the  child  pathological  processes  like 
those  in  the  breast  of  the  puerpera.  They  can  enlarge,  become 
painful,  the  skin  angry  red,  secretion  much  increased,  and  even  mam- 
mary abscess  develop. 

Treatment— A.YO\di  squeezing.  Apply  cooling  lotions,  as  lead- 
water  and  laudanum,  and  oil  the  skin  to  reheve  tension.  If  suppu- 
ration supervene,  poultice  and  open  early. 

IV.  Specific  or  Essential  Fevers. 

{a)  Exanthemata. 
{h)  Eiysipelas 
(c)  Malaria. 
{d)  Septicaemia. 

V.  Treatment  of  Certain  Congenital  Deformities. 

Hare-lip. -The  deformity   prevents  suckling,  hence  immediate 
plastic  operation  in  the  first  few  hours  of  life. 
^  Cleft-palate.— Too  serious  an  operation  to  be  undertaken  at  this 
time. 

Tongue-tie.— '^ni])  superficially  with  scissors  and  tear  with  fingers. 
Umbilical  Herma.—li  the  exomphalic  condition  be  even  the  size 
of  an  apple  an  immediate  plastic  operation  is  indicated. 

Spina  Bifida. — Non-interference,  or  consult  with  a  surgeon. 

VI.  Nasal  Catarrh. 

Causes.— W\(in  not  syphilitic,  usually  faulty  clothing,  ventilation 
or  temperature  of  the  room. 

VII.  Diseases  of  the  Mouth. 

(a)  Aphthm.—RoumlQ^^  pearl-colored  vesicles  seen  in  mouth  and 
on  lips.  Washing  the  mouth  daily  with  a  clean  linen  will  prevent 
them.     Boric  acid,  gr.  v-x  to  the  ounce,  is  curative. 

{h)  Thrush.— Coaleacence  of  white  spots,  with  an  areola  of  red- 
dened mucous  membrane.     Is  often  seen  in  hospital  practice.     Now 


54  OBSTETRICAL  LECTURES. 

thought  to  be  due  to  the  presence  of  a  parasite,  the  saccharomyces- 
albicans. 

Treatment. — ^Boric  acid,  gr.  xvj  to  xx  to  ^j  of  honey.  5ss  of  this 
three  or  four  times  a  day.  The  associated  symptoms  of  malnutrition, 
diarrhoea  and  vomiting  indicate  attention  to  hygienic  surroundings 
and  the  general  health  of  the  child. 

VIII.  Skin  Diseases. 

{a)  Gum.,  due  to  irritation  of  atmosphere  and  clothing.  Is  a 
papular  eruption  resembling  acne,  but  never  becoming  pustular. 

Treatment.  — Cleanliness,,  cosmoline,  and  proper  clothing. 

(6)  Simple  Acute  Pemphigus.  — Rare .  From  the  second  day  to 
the  fourth,  fifth  or  sixth  week,  vesicles  the  size  of  a  pea  to  a  quarter- 
or  half-dollar  appear  indifferently  over  the  whole  body  except  soles 
and  palms,  and  last  for  twelve  to  fourteen  days,  without  manifesta- 
tion of  constitutional  disturbance. 

Is  contagious  ;  may  be  carried  by  nurse,  and  may  be  communicated 
to  mother  or  nurse.     It  disappears  without  treatment. 

(c)  Syphilitic  Pemphigus. — Usually  occurs  in  utero.,  and  the  child 
is  born  with  vesicles,  the  soles  and  palms  most  often  affected.  The 
disease  is  associated  with  marked  evidences  of  malnutrition  and  con- 
stitutional disturbance,  and  yields  only  to  specific  treatment. 

IX.  Ophthalmia  Neonatorum. 

Symptom^s. — Usually  after  twenty-four  to  forty-eight  hours  the 
eyes  are  oedematous  and  puffed  out,  and  there  appears  a.  sero-purulent 
discharge,  which  is  soon  greenish  pus.  If  the  lids  can  be  separated 
the  conjunctivae  are  red  and  velvet-like  in  appearance,  and  later  the 
cornea  may  lose  its  epithelium,  ulcerate,  and  be  perforated. 

Treatment. — {a)  Prophylactic.  Crede  method.  As  soon  as  head 
is  born  warm  water  is  dropped  in  the  eyes.  When  the  delivery  is 
completed  the  eyes  are  again  cleansed  with  warm  water,  followed  by 
one  or  two  drops  of  a  ten-grain  solution  of  nitrate  of  silver.  A 
vaginal  douche  of  bichloride  is  not  always  effective,  because  the 
cervix  is  not  reached.  There  is  danger  of  poisoning  or  sending  air 
into  the  uterine  veins  if  the  cervix  be  injected. 

(6)  Curative.  The  eyes  are  cleansed  every  hour,  alternating  with 
a  concentrated  solution  of  boracic  acid  and  bichloride  of  mercury, 


PATHOLOGY   OF   NEWBORN   INFANT.  55 

1  to  5000  or  8000.  Morning  and  evening,  nitrate  of  silver,  20,  40  or 
60  grains  to  tlie  ounce,  is  dropped  in  the  eye.  If  only  one  eye  be 
affected,  bandage  the  other  carefully  with  a  pledget  of  lint  to  pro- 
tect it. 

X.  Hemophilia. 

A  disposition  to  bleed,  which  is  inherited.  The  maimer  of  trans- 
mission is  peculiar ;  always  through  mother  to  male  children,  who 
do  not  transmit  it.  The  female  children  show  no  evidences  of  it, 
but  do  transmit  it.  The  cause  is  not  known,  and  it  manifests  itself 
all  through  life.     Treatment  is  of  no  avail. 

XI.  Icterus. 

Two  classes  of  cases  : — 

{a)  Jaundice  very  light  in  degree.  Face  and  breast  only  affected. 
Very  common. 

Cause. — Hepatogenic.  Disappears  third  or  fourth  day  after  birth, 
and  requires  no  treatment. 

(b)  Whole  body  is  jaundiced.  Urine  and  feces  discolored  and  may 
contain  blood.     Is  rare. 

Cause. — Hepatogenic.  Is  also  seen  in  Buhl's  and  Winckel's  dis- 
eases and  in  septic  infection. 

Treatment  of  malignant  variety.  If  from  Buhl's  or  Winckel's 
diseases  or  from  septic  infection,  as  is  commonly  the  case,  is  usually 
fatal. 

XII.  Cyanosis. 

Causes.,  in  order  of  frequency :  Pneumonia  (usually  syphilitic), 
premature  birth,  malformation  of  heart  and  blood  vessels,  inter- 
ference with  nerves  of  respiration,  malformations  of  respiratory  tract, 
congenital  pleurisy,  partial  occlusion  of  trachea. 

XIII.  Diseases  of  Umbilicus. 

{a)  Septijc  Infection. — The  ulcer  is  covered  with  a  grayish  diph- 
theritic membrane,  has  a  reddened  areola,  and  may  lead  to  general 
infection. 

Treatment. — Prophylactic.  The  ulcer  should  be  exposed  at  the 
daily  bath,  cleaned  with   soap   and  water  and  dressed  with   sali- 


56  OBSTETRICAL  LECTURES. 

cylic  acid,  1  part ;  starch,  5  parts.  Tape,  soaked  in  an  ethereal  solu- 
tion of  iodoform  or  antiseptic  Chinese  silk,  should  be  used  to  ligate 
the  cord  at  birth.  Curative.  The  ulcer  to  be  touched  with  solution 
of  bichloride  (1  to  500),  and  dressed  as  above. 

(Jb)  Umbilical  Fungus. — An  overgrowth  of  granulations.  Cauter- 
ize with  nitrate  of  silver.  In  about  one-fifth  of  these  cases  nitrate 
of  silver  fails,  the  tumor  is  more  solid,  and  is  the  remains  of  the 
omphalic  duct  called  an  enteroteratoma.  It  should  be  ligated  and 
cut  ofi". 

(c)  Omphalitis. — A  peculiar  inflammation  of  the  umbilicus,  in 
which  the  abdomen  is  conical,  skin  and  subcutaneous  connecti-^ 
tissue  hard,  red  and  infiltrated.  It  is  always  septic  in  origin,  requires 
disinfection,  poultices  and  early  incisions,  with  stimulants  and  nour- 
ishment.    Prognosis  is  serious. 

{d)  Disease  of  Vessels. — Always  due  to  septic  infection,  and  invari- 
ably ends  in  general  septicaemia,  which  is  fatal. 

(e)  Hemorrhage. — (1)  From  the  vessels.  It  may  be  primary, 
from  careless  ligation,  or  secondary  (the  vessels  of  the  cord  close  from 
placental  end,  and  the  hypogastric  arteries  may  be  patulous  after 
the  cord  drops  ofi",  when  increased  blood  pressure  or  handling  the 
ulcer  may  bring  on  hemorrhage). 

Treatment. — If  bleeding  vessel  seen,  ligate.  Usually  requires 
Monsel  solution  and  pressure.  As  last  resort,  liquid  plaster-of-Paris, 
or  better,  transfix  with  hare-lip  pins  and  apply  figure-of-eight  liga- 
ture. 

(2)  Oozing  from  ulcer  after  the  cord  drops  ofi".  Rare.  Styptics 
or  cautery  will  not  control  it.  Requires  transfixion  and  figure-of-eight 
ligature. 

XIV.  Tetanus. 

Is  infectious.  Occurs  almost  exclusively  in  hospitals,  and  is 
usually  fatal. 

XV.  Melsena. 

An  extravasation  of  blood  into  stomach  and  intestines.  Duodenal 
ulcer,  some  congenital  defect  increasing  intra-abdominal  blood  pres- 
sure, or  hemophilia  may  be  the  cause. 

XVI.  Perforation  of  Intestines  and  Intussusception. 


PATHOLOGY   OF   THE  PUERPERAL   STATE.  57 

XVII.  Buhl's  Disease. 

Acute  fatty  degeneration  of  all  organs. 

Symptoms. — Icterus,  cyanosis,  diarrhoea,  vomiting,  etc.,  are  pres- 
ent, but  nothing  sufficiently  characteristic  to  make  a  diagnosis  before 

XVIII.  Winckel's  Disease. 
Acute   baemoglobinuria  with   jaundice,    cyanosis   and   fatty  de- 
generation of  all  organs. 

XIX.  Sudden  Death  of  Apparently  Well  Children. 

Causes. — {a)  Overlying  by  mothers,  accidentally  or  intentionally. 

(b)  Diseases  :  most  commonly  pneumonias,  apoplexies,  more  rarely 
perforation  or  intussusception,  or  other  diseases,  as  above. 

(c)  Occlusion  of  trachea  by  enlarged  thymus. 

Medication 

The  following  are  some  of  the  drugs  and  their  doses  required  in 
the  first  four  weeks  of  life.  Opium,  as  paregoric  2-5  gtt.,  lauda- 
num i-2^  gtt.,  mercury,  as  calomel  ya-s  gr-,  castor  oil  15  gtt.  to  3j, 
nitrate  of  silver  4V  grain,  etc. 

Pathology  of  the  Puerperal  State. 

I.  Abnormalities  of  Involution. 

These  may  be  anomalies  by  {A)  excess,  superinvolution,  (B)  by 
defect,  suhinvolution. 

Involution.  — The  old  theory  was  that  by  fatty  degeneration  and 
absorption  the  uterus  was  regenerated  from  the  embryonal  muscle 
cells  in  the  outer  layer.  This  has  been  disproved.  The  degeneration 
is  chiefly  fatty,  but  there  are  other  degenerative  processes  at  the 
same  time.  Regeneration  is  not  absolute,  i.  e.,  the  whole  muscle 
cell  is  not  destroyed,  but  loses  its  redundant  tissue.  The  process  is 
rather  an  atrophy,  and  stops  after  the  musole  fibre  reaches  its  original 
size.  This  same  process  affects  the  mucous  membrane,  peritoneum, 
uterine  adnexa,  vagina  and  vulvae.  Below  the  contraction  ring  it  is 
an  intermediate  process,  mainly  retraction  of  overstretched  tissue. 

{A)  Superinvolution. — An  exaggeration  or  abnormal  prolongation 


58  OBSTETRICAL  LECTURES. 

of  that  process  by  which  the  parturient  uterus  regains  its  normal 
conditions.  Is  rare.  Its  diagnosis  and  treatment  belong  to  Gynae- 
cology. 

(B)  Subinvolution. — A  retarded  or  arrested  involution. 

Causes. — (a)  Anything  increasing  bJood  supply,  as  hypertrophy 
of  mucous  membrane  during  pregnancy,  fibroids,  inflammatory  con- 
ditions resulting  from  sepsis,  mechanical  interference  with  pelvic 
circulation,  leading  to  its  engorgement,  as  heart  disease. 

(h)  Anything  interfering  with  contraction  of  uterine  muscle,  as 
retained  placenta,  polypoid  tumors,  large  masses  of  decidual  tissue, 
uterine  displacements,  distended  bladder  or  rectum,  dragging  adhe- 
sions. 

Diagnosis. — ^By  abnormalities  in  the  daily  diminution  in  size  of 
the  utenis. 

1st  day,  normally,  the  fundus  one  finger  above  umbilicus. 

2d  day,  the  fundus  level  with  navel. 

3d  and  4th  day,  the  fundus  a  trifle  below  navel. 

5th  and  6th  daj^,  the  fundus  two  fingers  below  navel. 

7th,  8th  and  9th  day,  the  fundus  three  to  four  fingers  above  sym- 
physis. 

10th,  ]lth  and  12th  day,  the  fundus  a  little  above,  at,  or  below 
symphysis. 

Involution  is  not  complete  for  six  weeks,  and  to  determine  the  size 
of  the  uterus  subsequent  to  its  retraction  below;  the  symphysis 
(12th  day),  the  following  intrauterine  measurements  have  been 
made : — 

10th  day lOj  cm.  5th  week 7 J  cm. 

15th    " 9.9"  6th      "     TtV" 

3d  week 8.8"  8th      "     Gj-V " 

4th    "    8      "  10th  and  12th  week  6j    " 

7  cm.  is  the  normal  measurement  of  the  non-pregnant  uterus, 
and  this  table  shows,  therefore,  a  physiological  super-involution 
which  is  overcome  by  subsequent  engorgement  of  uterine  vessels. 

Treatment — Varies  with  the  cause.  If  due  to  hypertrophied 
deciduge,  polypoids,  retention  of  placenta  or  placentae  succenturiatae 
— curette.  Never  allow  bladder  to  be  distended,  nor  constipation  to 
exist.     Correct  displacements,  combat  septic  inflammation,  treat  any 


PATHOLOGY   OF  THE  PUERPERAL   STATE.  59 

heart  disease,  and  if  fibroids  be  the  cause,  give  a  pill  of  ergot, 
strychnise  and  quinia,  and  administer  faradism  daily.  The  routine 
administration  of  ergot  not  recommended.  It  does  not  secure  contrac- 
tion, and  often  has  ill  effect  upon  the  child  through  the  mother's  milk. 

IT.  Puerperal  Anemia. 

A  subinvolution  of  the  blood.  The  physiological  hydraemia  of 
pregnancy  fails  to  disappear. 

Causes. — Any  wasting  or  depressing  disease,  loss  of  blood  from 
post-partum  or  other  hemorrhages,  cancer,  puerperal  chorea,  or  in- 
sanity. 

Prognosis. — Yields  usually  to  timely  treatment.  May  progress  to 
pernicious  anemia  if  neglected. 

Treatment. — Iron  (Blaud's  pill).  Arsenic  seems  to  be  needed  in 
some  cases. 

III.  Repair  of  Injuries  after  Labor. 

Slight  lacerations  and  tears  heal  rapidly.  Even  extensive  inju- 
ries, as  fistulas,  sometimes  heal  spontaneously.  Small  sloughs 
should  be  touched  with  nitric  acid.  Lacerations  of  the  cervix,  if 
productive  of  serious  hemorrhage,  should  be  closed  by  suture. 
Always  stitch  a  laceration  of  the  perineum  when  beyond  a  half-inch 
in  length,  being  careful  to  apply  sutures,  so  that  fistulse  may  not 
result.  When  the  perineum  has  been  torn,  a  douche  is  given  after 
delivery  of  the  placenta,  and  absorbent  cotton  soaked  in  10  per  cent, 
solution  of  cocaine  is  placed  in  the  vagina,  while  the  doctor  prepares 
his  instruments  to  repair  the  injury.  If  the  sphincter  has  been  torn, 
the  two  edges  are  united  by  interrupted  catgut  sutures.  Any  tear 
in  the  vagina  should  be  repaired  by  continuous  catgut  suture.  The 
perineal  tear  is  united  by  silkworm-gut  sutures  clamped  with  shot. 

Any  of  these  injuries  will  produce  an  immediate  elevation  of  tem- 
perature after  labor  above  the  normal  rise. 

IV.  Puerperal  Hemorrhages. 

Hemorrhages  occurring  during  the  pjierperium,  from  24  hours 
after  labor  until  the  completion  of  involution  (6  weeks).  Hemor- 
rhage is  called  post-partum  when  it  occurs  within  the  first  24  hours 
after  labor. 


60  OBSTETRICAL  LECTURES. 

Causes,  in  Order  of  Frequency  : — 

{a)  Retained  Secundines. 
(h)  Displaced  Uterus. 
(c)  Displaced  Thrombi. 
{d)  Emotion, 
(e)  Relaxation  of  Uterus. 
(/)  Retained  Clots. 
ig)  Fibroids. 
{h)  Hsematomata. 
[i)  Pelvic  Engorgement. 
ij)  Secondary  Bleeding. 
{k)  Carcinomata, 
Retained  Secundines. — Always  examine  placenta  to  see  if  a  part 
lias  been  retained,   and  remove  antiseptically  with  the  finger  any 
fragments  left  in  the  uterus.     If  more  than  one-third  of  the  mem- 
branes are  retained  they  should  be  similarly  removed. 

Displaced  Uterus. — When  lateral,  anterior  or  posterior,  hemorrhage 
is  due  to  the  congestion  or  retention  of  blood  from  mechanical  ob- 
struction. In  the  latter  clots  will  be  discharged.  This  congestion, 
with  loss  of  tonicity,  often  develops  subinvolution.  Backward  dis- 
placement is  frequently  caused  by  a  (1)  sudden  effort,  especially  if 
patient  is  out  of  bed  too  early  (2)  misplaced  compress,  (3)  over-dis- 
tended bladder.  Inversion  and  prolapse  considered  later.  In  all 
cases  the  bladder  should  be  emptied  and  uterus  replaced. 

Displaced  Thromhi. — Perfect  quiet  should  be  secured  to  prevent 
dislodgement  of  the  thrombi .  formed  in  the  uterine  sinuses.  The 
most  dangerous  is  when  they  are  disintegrated  by  microbes  with  the 
development  of  septicaemia. 

Treatment. — As  hemorrhage  from  this  cause  is  usually  sudden, 
and  alarming,  at  once  apply  an  intra-uterine  tampon  of  iodoform 
gauze. 

Emotion. — How  it  produces  hemorrhage  is  not  known.  Probably 
by  interference  with  blood  pressure  or  causing  relaxation  of  the 
uterus. 

Relaxation  of  Uterus. — Karely  occurs.  Almost  never  after  the 
third  day  and  even  before  this  time,  only  in  women  of  poor 
physique. 

Treatment. — Same  as  for  post-partum  hemorrhage. 


PATHOLOGY   OF  THE  PUERPERAL   STATE.  61 

Retained  Clots. — Rarely  a  primaiy  cause,  but  (jften  secondary  to 
retained  placenta,  flexions,  etc. 

Fihy^oids. — Always  cause  excessive  lochia  and  usually  produce 
liemorrhage. 

Treatment. — A  pill  of  strychnia,  ergot  and  quinine.  If  severe, 
an  intrauterine  tampon. 

Hcematomata. — Is  an  interstitial  bleeding,  submucous  or  subcu- 
taneous. The  resulting  tumor,  which  is  usually  globular  in  shape, 
may  be  situated  on  one  or  both  labise,  in  the  cervix  or  broad  liga- 
ment, etc.     The  very  small  ones  are  more  frequent. 

Causes. — (a)  Predisposing. — Pelvic  engorgement  and  straining 
during  labor.     Marked  anteversion. 

[h)  Exciting. — Rupture  of  a  blood  vessel,  usually  a  vein  of  large 
size,  from  straining,  a  blow  or  forceps. 

Symptoms. — The  rupture  occurs  during  the  second  stage  of  labor, 
accompanied  by  sharp,  lancinating  pain  and  painful  expulsive  efforts, 
the  tumor  usually  appearing  after  labor  is  completed. 

Pcognosh. — Death  may  occur  from  hemorrhage  or  sepsis,  but 
ought  to  be  exceptional. 

Treatment. — Secure  absorption  if  not  larger  than  one's  fist,  by 
cleanliness,  rest,  cooling  applications  and  antiseptic  douches.  If 
larger,  wait  until  it  ceases  to  increase  in  size  (except  when  it  appears 
between  the  birth  of  twins  or  prevents  escape  of  lochia),  when  it 
should  be  incised  and  turned  out.  Coptrol  hemorrhage  when  sac 
ruptures  by  ligation  or  iodoform  gauze  compress.  To  control  the 
bleeding  into  the  sac  when  the  tumor  first  appears,  resort  to  cold  and 
pressure  with  the  largest  size  Barnes'  bag.  The  danger  of  sepsis 
contraindicates  an  ordinary  tampon. 

Pelvic  Engorgement. — May  arise  from  too  early  sexual  intercourse, 
increased  intra-abdominal  pressure  from  liver  or  heart  disease,  sub- 
involution, etc.,  thus  proloHging  the  bloody  lochia. 

Secondary  Bleeding. — From  laceration  of  vessels  along  the  par- 
turient tract,  especially  about  the  meatus,  the  hemorrhage  recurring 
after  the  pressure  of  the  child's  head  is  removed. 

CardnowMta. — Of  the  cervix.  Rarely  may  develop  suddenly  at 
the  placental  site  and  end  fatally  in  a  few  weeks  or  months. 


62  OBSTETRICAL  LECTURES. 

V.  Anomalies  of  the  Breasts. 

Galactorrhoea. — Rarely  is  the  milk  supply  excessive  for  the 
requirements  of  the  child. 

Cause.  — None  satisfactory.  Plethora,  anemia,  phthisis  have  been 
reported  as  causes. 

Treatment. — Unsatisfactory.  The  best,  perhaps,  is  pressure,  ergot 
and  potassium  iodide.  Electricity  and  local  astringents  have  been 
recommended. 

Anatomical  Defects.  — 1 .  Congenital  absence  of  or  supernumerary 
glands. 

2.  Inversion  of  Nipple. — Rather  common  in  modern  girls,  from 
pressure  of  corsets.     Should  always  be  looked  for. 

Treatment. — Evert  with  breast  pump,  only  in  last  month  of  preg- 
nancy to  avoid  miscarriage  from  refiex  contraction  of  uterus.  If  the 
pump  fails  resort  to  a  shield,  and  finally  artificial  feeding. 

3.  Fissured  Nipple. — Causes.  — Maceration  and  irritation  of  nipple. 
Mammary  abscess  frequently  results  from  it. 

Treatment. — {a)  Propliylactie. — During  the  latter  months  of  preg- 
nancy the  nipple  should  be  washed  and  greased  with  sweet  oil  twice 
a  day,  and  receive  a  daily  bath  with  a  saturated  solution  of  alum. 
Avoid  alcoholic  astringents,  and  keep  the  nipple  clean  during  lacta- 
tion. 

(Jb)   Curative. — Apply  tinct.  benzoin  comp. 

Inflammations  of  the  Breasts.  — {a)  Of  the  subcutaneous  connective 
tissue. 

(6)  Of  the  deeper  interstitial  tissue. 

(c)  Parenchymatous. 

Causes. — Of  the  first  two  classes  a  large  proportion  are  due  to 
sepsis.  Parenchymatous  inflammation  need  not  be  from  this  cause. 
Over  activity  of  the  gland  with  retained  secretion  (the  so-called 
' '  caked  breast ' ' )  may  be  the  cause. 

Treatment. — If  parenchymatous  and. due  to  over  secretion  empty 
with  pump  or  by  massage.  If  of  the  connective  tissue  and  abscess 
is  threatened,  apply  leadwater  and  laudanum  and  a  mammary 
binder.  Suckling  had  best  be  intermitted,  as  the  secretion  is  apt  to 
disagree  with  the  child,  and  rarely  has  given  rise  to  septic  infection 
of  the  intestines. 


PATHOLOGY   OF  THE   PUERPERAL   STATE.  63 

Abscess. — The  pus  may  be  located  : — 
(a)  Superficially. 
(h)  In  the  gland  substance. 
(c)  Post-mammary. 

Symptoms  of  Suppuration. — Uncertain.  The  reddened  skin, 
fever,  bogginess,  etc. ,  may  be  due  to  other  causes,  and  fluctuation 
rarely  detected  until  late. 

Treatment. — Be  prompt ;  err  on  safe  side  by  making  an  early 
incision,  radiating,  through  skin,  and  then  locate  abscess  with  di- 
rector. Wash  several  times  a  day  with  antiseptic  solution,  and 
apply  pressure,  to  prevent  further  burrowing.  If  fistulae  result,  resort 
to  firm  pressure,  drainage  and  antisepsis. 

When  the  abscess  is  post-mammary  the  whole  breast  is  lifted  off 
the  chest  and  there  are  no  signs  on  the  surface. 

Treatment. — Incise  beyond  the  periphery  of  the  gland  at  the  more 
dependent  part,  pass  a  drainage  tube  through  a  counter-opening, 
and  dress  antiseptically. 

Galactocele — A  milk  tumor  due  to  occlusion  of  one  of  the  lactifer- 
ous ducts.     Usually  of  no  pathological  importance. 

VI.  Diseases  of  the  Urinary  Apparatus. 

Cystitis.     Pyelitis. — The  use  of  dirty  catheters  a  frequent  cause. 

VII.  Diseases  of  the  Nervous  System. 

Insanity  may  occur  during  pregnancy,  labor  or  lactation.  During 
pregnancy  it  is  apt  to  be  melancholia  ;  after  labor,  mania. 

Prognosis. — Tolerably  good.  Two-thirds  to  three-fourths  recover. 
Death  may  occur  from  maniacal  exhaustion  or  septic  infection. 

Treatment. — Isolation.     Rest  cure. 

VIII.  Puerperal  Fever. 

Puerperal  fever  is  an  elevation  of  temperature  during  the  puer- 
perium. 

Classification : — 

I.  Infectious.     II.  Non-infectious. 

The  infectious  may  be  further  classified  as  follows  : — 

A.  Those  in  which  the  infecting  poison  enters  through  wounds  in 
the  genital  canal  or  immediate  neighborhood. 


64  OBSTETRICAL  LECTURES. 

(a)  The  pathogenic  agent  a  microbe. 

(b)  The  pathogenic  agent  a  ptomaine. 
B.    Those  in  toMch  the  poison  enters  other  channels. 

Septicemia,  a  name  commonly  given  to  the  disease  resulting  from 
the  invasion  of  the  body  by  microbes  and  their  products,  may  be 
due  to  a  very  great  variety  and  number  of  microorganisms.  In  the 
appended  chart  will  be  found  a  list  of  those  discovered  up  to  this 
time: — 

Streptococcus  pyogenis. 

Streptococcus  erysipelatis. 
Bacillus  oedematis  maligni. 
Staphylococcus  pyogenis  aureus. 
Micrococcus  of  osteomyelitis, 
Staphylococcus  pyogenis  albus. 
Micrococcus  pyogenis  tenuis. 
Staphylococcus  pyogenis  citreus. 
Staphylococcus  cereus  albus. 
Staphylococcus  cereus  flavus. 
Bacillus  saprogenis,  1. 
Bacillus  saprogenis,  2. 
Bacillus  saprogenis,  3. 
Bacillus  pyogenis  fetidus. 
Staphylococcus  salivarius  septicus. 
Coccus  salivarius  septicus. 
Bacillus  salivarius  septicus. 
Bacillus  of  chicken  cholera. 
Bacillus  of  rabbit  septicaemia. 
Bacillus  of  pseudo-oedema. 
Bacillus  of  mouse  septicaemia. 
Mouse-septicaemia-like  bacillus. 
Diplococcus  pneumoniae. 
Bacillus  resembling  pneumonia  bacillus. 
Diplococcus  intra-cellulosis  meningitidis. 
Bacillus  septicus  agrigenus. 
Streptococcus  pyogenis  malignus. 
Streptococcus  septicus. 
Streptococcus  septo-pysemicus. 


PATHOLOGY   OF  THE  PUERPERAL   STATE.  65 

Streptococcus  articulorum. 

Bacillus  necrophonis. 

Brieger's  bacillus. 

Emerick's  bacillus. 

Bacterium  coli  commune. 

Bacillus  of*  intestinal  diplitlieria. 

Micrococcus  botryogenus. 

Micrococcus  of  progressive  lympbomata. 

Bacillus  of  rhinoscleroma. 

Tetanus  bacillus. 

Bacillus  of  acne  contagiosa  (Harold  Ernst). 

1.  Infectious  Fevers. 

A.  The  more  common  variety  of  infectious  puerperal  fever  is  that 
due  to  the  absorption  of  ptomaines  through  wounds  in  the  genital 
canal.  The  microbes,  which  duiing  decomposition  generate  the 
absorbed  ptomaines,  may  gain  access  from  doctor,  nurse,  instruments 
or  atmosphere  charged  with  putrescible  material,  and  attack  clois, 
portions  of  hyjoertrophied  mucous  membrane,  etc. 

Diagnosis. — The  symptoms  of  septic  poisoning  are — 

(a)  Local.  — 1 .   Putrid  discharge. 

2.  (Edema  of  vulvae. 

3.  Diphtheritic  patches. 

(Jj)  General. — 1.  Fever,  usually  preceded  by  a  chill,  although  a 
fatal  case  may  occur  without  fever. 

2.  Peritonitis — develops  with  spread  of  poison,  although  it  may  be 
entirely  absent. 

3.  Other  organs  infected  by  the  microbes,  as  kidneys,  lungs, 
spleen,  brain,  with  development  of  corresponding  symptoms.  The 
result  of  treatment  can  alone  determine  whether  in  any  case  the 
symptoms  be  due  to  the  absorption  of  microbes  or  ptomaines — i.  e. , 
it  is  impossible  to  diagnosticate  the  absorption  of  ptomaines,  as  such, 
from  the  symptoms  alone.  Elevation  of  temperature  during  the 
puerperium  may  arise  from  many  causes,  but  should  be  treated  as 
septic  until  proven  to  be  otherwise.  In  this  climate  it  is  most  com- 
monly mistaken  for  malaria. 

Treatment. — The  indications  are  (1)  to  stop  the  manufacture  of 
these  poisonous  bodies,  which  is  best  accomplished  by  destroying  the 


66  OBSTETRICAL  LECTURES. 

microbes  and  removing  their  habitat,  and  (2)  sustain  strength  to  aid 
the  struggle  between  the  body  cells  and  microbes.  The  first  is 
accomplished  by  douches,  vaginal  and  intra-uterine,  the  use  of  the 
curette,  intra-uterine  ujipers,  forceps.  In  skillfal  hands  the  curette 
is  best.  Hirst' s  sharp  curette  requires  some  care  and  skill.  Munde'  s 
wire  curette  is  less  dangerous,  but  less  effective.  Doleris'  ecou- 
villon  may  be  used  in  an  emergency. 
The  Operation. — 

1.  The  hands  and  arms  washed  with  bichloride  solution,  1  to  1000. 

2.  Yaginal  Douche. — 2  per  cent,  solution  of  creolin  (five  drachms 
to  a  quart  of  water). 

3.  Curette  passed  to  fundus,  and  whole  cavity  of  uterus  gently 
scraped,  using  only  the  force  of  the  thumb  and  first  finger.  Remove 
debris  with  forceps. 

4.  Intrauterine  Douche. — Fountain  syringe,  a  two-way  catheter 
(Lentz  or  Bozeman),  a  quart  of  2  per  cent,  solution  creolin,  or  bi- 
chloride solution  1  to  4000.  If  the  latter  be  used,  the  uterus  should 
always  be  immediately  washed  out  with  sterilized  water.  Douches 
to  be  given  once  in  twenty-four  hours.  A  heavy  dose  of  quinia 
should  be  given  for  the  fever  and  to  eliminate  any  malarial  origin  of 
the  elevated  temperature.  When  the  sj^mptoms  are  due  to  the 
absorption  of  ptomaines,  this  treatment  will  be  followed  by  their 
speedy  disappearance.  If  they  continue,  the  second  indication — in 
which  the  treatment  is  only  palliative  and  symptomatic — is  met  by  a 
fuU  diet  of  milk,  two  or  more  quarts  in  twenty-four  hours,  if  assim- 
ilated ;  partially  digested,  if  necessaiy,  and  large  quantities  oi  stimu- 
lants, one  pint  or  more  in  twenty-four  hours,  of  whisky,  wine  or 
brandy. 

'EoYt\iQ  peritonitis  apply  light  poultices  twice  a  day,  with  a  stupe 
while  the  former  are  being  changed.  Sufficient  opium  to  relieve 
pain  is  demanded.  Bleeding  and  salines  are  too  debilitating  and 
should  be  avoided  in  septic  peritonitis.  Treat  other  complications 
on  general  principles. 

Prognosis. — Large  majority  recover  with  appropriate  treatment. 
As  a  rule,  if  temperature  be  high,  internal  organs  involved,  if  there 
are  repeated  chills,  the  pulse  weak  and  fluttering,  the  prognosis  is 
more  grave,  but  death  may  occur  without  these  being  present. 


PATHOLOGY   OF  THE  PUERPERAL  STATE.  67 

Phlegmasia  Alba  Dolens^  or  Milk  Leg. — There  are  two  classes  of 
cases  : — 

1.  Thrombosis  of  veins  of  thigh. 

2.  Connective  tissue  of  thigh  affected. 
Symptoms. — From  the  tenth   to  thirtieth   day  there  develops  a 

heaviness  and  stiffness  in  the  leg,  soon  followed  by  swelling,  occurring 
in  different  localities,  at  the  ankle,  gradually  ascending  to  the  groin 
(if  due  to  thrombosis  of  the  veins),  or  at  Poupart's  ligament  extend- 
ing down  the  thigh  (if  due  to  involvement  of  the  connective  tissue). 
Fever  is  evanescent,  and  usually  disappears  before  swelling  subsides. 

Cause. — Septic  infection. 

Prognosis. — Grrave,  death  resulting  from  general  septic  infection, 
or  embolism. 

Ti^eatment. — The  condition  is  asthenic  in  tendency,  hence  treat- 
ment should  be  supporting  and  stimulating.  Enjoin  absolute  quiet 
and  rest  in  bed  to  avoid  embolism.  Elevate  the  limb,  wrapped  in 
cotton,  and  when  convalescent  resort  to  cautious  massage. 

Preventive  Treatment  of  Puerperal  Fever. — Secure  absolute  clean- 
liness of  doctor,  nurse,  patient,  instruments,  atmosphere,  etc. 

Hands. — Washed  with  soap  and  water  followed  by  immersion  in 
alcohol  and  solution  of  bichloride  1  to  1 000. 

Instrmnents. — 2  per  cent,  solution  creolin.  In  hospital  work  the 
bedding  should  be  washed  in  bichloride  solution,  and  the  patient 
given  a  bath  just  before  labor. 

Atmosphere. — Selection  of  well  ventilated  room  is  important. 
Use  occlusive  dressing  of  corrosive  cotton  and  gauze,  which  should 
be  changed  frequently. 

External  Genitals. — Cleaned  when  each,  pad  is  applied,  never 
using  a  sponge,  but  preferably  baked  cotton,  or  corrosive  jute. 

{B)  Puerperal  fever  in  which  the  poison  enters  other  channels 
a.  e. ,  not  through  wounds  of  genital  canal,  etc. ).  Includes  any  of 
the  infectious  diseases,  as  the  exanthemata,  etc.  When  these  dis- 
eases occur  during  the  puerperium,  their  course  is  often  modified. 
Incubation  is  usually  shortened  and  convalescence  prolonged.  Their 
diagnosis  is  always  obscure,  as  it  is  apt  to  be  confounded  with  sepsis ; 
the  germs  of  any  of  them,  when  introduced  through  wounds  in  the 
genital  canal,  producing  about  the  same  symptoms.  Their  jDrognosis 
is  more  unfavorable. 


68  OBSTETRICAL  LECTURES. 

II.  Non-infectious  Fevers. 

The  temperature  of  women  during  the  puerperium  is  very  variable, 
and  easily  influenced  by  causes  which  in  health  would  have  no  effect. 
Non-infectious  puerperal  fever  may  be  due  to  : — 
{a)  Emotion. 
(6)  Exposure  to  cold, 
(c)  Constipation. 
{d)  Reflex  irritation, 
(e)  Cerebral  diseases. 
(/)  Eclampsia. 
{g)  Insolation. 
Qi)  Syphilis. 

{i)  Exacerbations  of  acute  or  chronic 
diseases  contracted  during  or 
before  pregnancy. 
Influence  of  child-hearing  upon  Phthisis. — The  laity  believe  it  to 
be  favorable.     This  is  not  the  fact.     Pregnancy,  the  puerperal  state 
and  lactation  are  a  drain  on  woman's  strength,  and  can  cause  the 
development  of  phthisis  in  those  predisposed  to  it.      If  already 
present  the  symptoms  are  exacerbated. 


SYLLABUS  OF  OBSTETRIC  LECTURES. 


LECTURES  TO  THE  COMBINED  CLASSES. 


PART  II. 


Anatomy  of  the  Pelvis  Obstetrically  Considered. 

The  false  pelvis  is  that  expanded  portion  situated  above  the  Hio- 
pectineal  line. 

The  true  pelvis  is  that  part  of  the  cavity  beneath  the  iho-pectineal 
hne. 

I.  Position. 

The  obhqnity  to  the  spinal  column  and  trunk  in  the  erect  posture 
is  55°  at  the  superior  strait,  10°  at  the  inferior  strait. 

II.  Shape. 

The  false  is  irregularly  fannel-shaped,  exerts  no  special  influence  on 
the  course  of  labor,  and  is  accessory  to  the  true,  seizing  to  direct  the 
presenting  part  into  the  true.  The  true  is  similar  to  a  truncated 
cylinder,  five  inches  in  depth  behind,  one  and  a  half  in  front,  and 
three  and  a  half  laterally. 

The  shape  of  the  inlet  or  superior  strait  is  most  frequently 
cordiform.  May  be  circular  or  elliptical.  The  shape  of  the  cavity 
is  chiefly  noted  for  its  irregularity,  and  the  outlet  or  inferior  strait 
is  cordiform. 

III.  Size. 

(a)  Inlet. — The  antero-posterior  or  conjugate  diameter,  measured 
from  the  upper  edge  of  the  promontory  of  the  sacrum  to  a  point  an 
eighth  of  an  inch  below  the  upper  border  of  the  symphysis,  is  11  cm. 

69 


70  OBSTETRICAL  LECTURES. 

The  transverse^  the  longest  possible  transverse  distance,  is  ISJ  cm. 
The  oblique^  from  upper  edge  of  one  sacro-iliac  junction  to  opposite 
ilio-pectineal  eminence,  is  12f  cm. 

(6)  Cavity.— Th.Q  plane  of  pelvic  expansion  perforates  the  middle 
of  the  symphysis,  tops  of  acetabula,  and  the  sacrum  between  the 
second  and  third  vertebrae. 

Diameters.:  antero-posterior  12|  cm.;  transverse  12J  cm. 

The  plane  of  pelvic  contraction  passes  through  tip  of  sacrum, 
spines  of  ischia  and  under  surface  of  symphysis. 

Diameters  :  antero-posterior  11 2-  cm.;  transverse  10 J  cm. 

(c)   Outlet. — Antero-posterior  92^  cm.;  transverse  11  cm. 

lY.  Direction  of  Pelvic  Canal. 

Represented  by  a  curved  line  parallel  to  concave  surface  of  sacrum, 
and  equally  distant  from  sides  of  pelvis  (curve  of  Carus). 

Development  of  Adult  Pelvis. — The  foetal  pelvis  represents  a  funnel, 
and  the  development  of  the  irregularities  and  peculiarities  of  the 
adult  pelvis  may  be  accounted  for  by  three  factors,  viz. : — 

(a)  Weight  of  the  body,  (6)  counter-pressure  of  the  femora,  (c) 
force  exerted  by  the  ligaments.  The  sacral  curve  and  lateral  aspects 
are  thus  explained. 

The  Bony  Pelvis  Filled  with  Soft  Tissues. 

{a)  Muscles. — Ilio-psoas,  obturator  internus,  pyriformis,  coccygeus, 
levator  ani,  retractor  ani,  sphincter  ani,  constrictor  vaginae,  trans- 
verse perinei.  The  levator  ani  plays  a  most  important  part  in  the 
sexual  life  and  physiology  of  woman.  A  vigorous  contraction  of 
this  muscle  pulls  the  rectum  and  vagina  towards  the  symphysis,  and 
when  distended  during  labor,  serves  to  direct  the  head  out  under 
the  symphysis,  thus  relieving  the  strain  on  the  perineum.  It  is 
active  during  the  orgasm  in  the  female,  and  directs  the  male  organ 
toward  the  cervical  canal. 

During  parturition  the  function  of  the  muscles  of  the  pelvic  canal 
(ilio-psoas,  obturator,  pyriformis,  etc.,)  is  mechanical.  They  serve 
as  bumpers  or  protectors  to  the  bony  wall,  and  deflect  the  presenting 
part  in  the  most  favorable  direction  for  its  expulsion.  The  situation 
of  the  ilio-psoas  muscles  diminishes  the  transverse  diameter  of  the 
inlet,  so  that  in  the  pelvis  during  life,  the  diagonal  is  the  greatest 


ANATOMY   OF  THE  PELVIS   OBSTETRICALLY  CONSIDERED.        71 

diameter,  thus  explaining  the  great  frequency  of  obhque  positions 
of  the  presenting  part. 

The  muscles  of  the  pelvic  floor  (levator  ani,  coccygeus,  transverse 
perinei,  etc.,)  are  passive,  in  one  sense,  during  parturition.  They 
yield  only  outward  and  backward,  and  by  resisting  the  passage  of 
the  presenting  part,  are  frequently  lacerated,  yet  the  direction  of 
their  resistance  serves  to  deflect  the  head  outward  and  upward  under 
the  symphysis. 

{b)  Ligaments. — The  ohturator  membrane  closes  the  foramen  and 
serves  as  a  cushion  to  protect  the  presenting  part.  The  sacro-sciatic 
ligaments  close  the  pelvic  wall,  afford  protection  and  give  direction 
to  the  presenting  part. 

(c)  Conneqtice  Tissue. — A  knowledge  of  the  distribution  of  the 
pelvic  fascia  is  of  importance  in  determining  the  course  of  extension 
of  interstitial  bleeding  or  absorbed  infecting  organisms.  From  both 
sides  of  the  uterus  the  connective  tissue  extends  in  three  directions. 
Laterally,  it  is  included  in  the  broad  ligament,  and,  traveling  along 
the  round  ligament,  it  reaches  the  mons  veneris  and  inguinal  region. 
Anteriorly,  it  skirts  the  bladder  and  is  continuous  with  the  sub- 
cutaneous connective  tissue  of  the  abdominal  wall.  Posteriorly,  it 
skirts  the  rectum,  is  included  in  the  meso-rectum,  and  is  continuous 
with  the  connective  tissue  of  the  posterior  abdominal  wall.  It  also 
follows  the  three  canals  which  perforate  the  pelvic  floor,  the  urethra, 
vagina  and  rectum,  and  thus  is  continuous  with  the  subcutaneous 
connective  tissue  of  the  external  genitalia  and  perineum. 

{d)  Blood  Vessels. — The  ovarian  arteries,  leaving  the  abdominal 
aorta,  enter  the  pelvis  on  either  side,  and  passing  between  the 
laminae  of  the  broad  ligament,  are  distributed  to  the  ovaries  and 
tubes,  a  branch  going  to  the  fundus,  another  traversing  the  uterus 
to  anastomose  with  a  branch  of  the  uterine  artery.  The  uterine 
artery  passes  downward  from  the  anterior  trunk  of  the  internal  iliac 
to  the  neck  of  the  uterus.  Ascending  the  sides  of  the  uterus,  a 
branch  meets  the  ovarian,  and  a  branch,  the  circidar  artery  of  the 
cervix,  supplies  the  cervix.  The  latter  is  sometimes  ruptured  during 
labor,  or  cut  during  operations  upon  the  cervix,  and  gives  rise  to 
pronounced  hemoiThage.  The  venous  supply  to  the  pelvis  is  very 
abundant. 

(e)  Lijmphaiics. — Important  in  their  relation  to  septic  absorption. 


72  OBSTETRICAL  LECTURES. 

The  lympli  spaces  of  tlie  uterus,  lying  between  connective-tissue 
bundles,  and  covered  witb  endothelial  cells,  empty,  by  means  of 
their  ducts,  into  the  lymphatic  glands.  These  lead  to  the  thoracic 
duct.  The  most  important  glands  are  the  uterine,  inguinal,  obtu- 
rator, hypogastric,  lumbar  and  sacral. 

(/)  Nerves. — Principally  from  sj^mpathetic  system.  The  uterine 
plexus  sends  off  the  two  hypogastric  plexuses,  and  from  these  fila- 
ments] pass  to  ovaries  and  uterus. 


Deformities  of  the  Pelvis. 

4 

(Classification  of  Schauta.) 

A.  Anomalies  of  the  Pelvis  the  Result  of  Faulty 

Development. 

(1)  Simple  Flat. 

(2)  Generally  Equally  Contracted  (justo-minor). 

(3)  Grenerally  Contracted  Flat  (non-rachitic). 

(4)  Narrow  Funnel-shaped. 

Foetal  or  Undeveloped. 

(5)  Imperfect  Development  of  One  Lateral  Mass  of  Sacrum.   (Nae- 

gele's  Pelvis.) 

(6)  Imperfect  Development  of  Both  Lateral  Masses.     (Roberts' 

Pelvis.) 

(7)  Grenerally  Equally  Enlarged  (justo-major). 

(8)  Split  Pelvis. 

B.  Anomalies  due  to  Disease  of  the  Pelvic  Bones. 

(1)  Rachitis. 

(2)  Osteomalacia. 

(3)  NewG-rowths. 

(4)  Fractures. 

(5)  Atrophy,  Caries  and  Necrosis, 

C.  Anomalies  in  the  Conjunction  of  the  Pelvic  Bones. 

(«)  Too  firm  union  (synostosis). 

(1)  Of  symphysis. 

(2)  Of  one  or  both  sacro-iliac  synchondroses. 

(3)  Of  sacrum  with  coccyx. 


DEFORMITIES   OF   THE  PELVIS.  73 

{h)  Too  loose  a  union  or  separation  of  the  joints. 

(1)  Relaxation  and  rupture. 

(2)  Luxation  of  the  coccyx. 

D.  Anomalies  due  to  Disease  of  the  Superimposed 

Skeletox. 

(1 )  Spondj'lolisthesis. 

(2)  Kyphosis. 

(3)  ScoUosis. 

(4)  Kypho-scoliosis. 

E.   Anomalies  due  to  Disease  of  Subjacent  Skeleton. 

(1)  Coxalgia. 

(2)  Luxation  of  One  Femur. 

(3)  Luxation  of  Both  Femora. 

(4)  Unilateral  or  Bilateral  Club  Foot. 

(5)  Absence 'or  Bowing  of  One  or  Both  Lower  Extremities. 
The  simple  flat  pelvis  is  the  most  frequent  variety  in  this  countiy. 

The  contraction  is  at  the  conjugate  diameter  of  the  inlet.  The 
narrow,  funnel-slmx)ed  pelvis  occurs  in  those  whose  bony  develop- 
ment has  ceased  or  in  those  who  never  have  walked.  In  the  latter 
the  three  developmental  factors  which  produce  the  normal  adult 
pelvis  have  been  inoperative.  In  the  split  pelvis  the  deformity  is  at 
the  symphysis  and  is  associated  with  extrophy  of  the  bladder.  The 
characteristics  of  the  rachitic  pelvis  are  :  excessive  rotation  of  the 
sacrum  on  its  transverse  axis,  resulting  in  an  abnormal  projection  of 
the  promontory  and  increased  sacral  curve  ;  the  curve  of  the  iliac 
bones  is  exaggerated  and  their  anterior  spines  more  widely  separated. 
This  form  is  next  in  frequency  to  the  simple  flat  in  this  country. 
The  greatest  contraction  is  in  the  conjugate  at  the  brim.  Osteo- 
malacia is  very  rare  in  this  country.  It  gives  rise  to  the  ' '  beak- 
like" projection  at  the  symphysis.  The  neio  growths  causing  de- 
formity may  be  any  of  the  tumors  that  can  develop  from  bone. 

When  the  pelvic  joints  are  too  firmly  united  the  phy.siological 
loosening  which  happens  during  the  latter  months  of  pregnancy  can- 
not occur.  Anchylosis  of  the  sacro-coccygeal  joint  is  not  infrequent 
in  old  primiparae.  Spondylolistliesis  is  a  slipping  down  of  the  last 
lumbar  vertebra  into  the  pelvic  cavity.     In  lajpliosis  the  weight  of 


74  OBSTETRICAL  LECTURES. 

the  body  is  from  above  downward  and  from  before  backward.  The 
sacrum  is  thus  pushed  backward,  increasing  the  diameters  of  the 
inlet  but  diminishing  the  outlet.  The  distortion  resulting  from 
scoliosis  is  a  lateral  displacement  of  the  promontory  giving  rise  to  an 
oblique  deformity.  Lordosis  is  the  compensatory  curve  seen  in 
kyphosis. 

Pelvimetry. 

Table  of  Measurements. 

Pelvis. 
Iliac  spines,  26  cm. 
Iliac  crests,  29  cm. 
External  conjug.,  20^  cm. 
Internal  conjug.,  diagonal,  12f  cm. 
True  conjug.,  estimated,  11  cm. 
Eight  diagonal,  22  cm. 
Left  diagonal,  22  cm. 
Between  Trochanters,  31  cm. 
Circumference  of  Pelvis,  90  cm. 

An  accurate  measurement  of  the  pelvis  by  means  of  the  pelvi- 
meter will  disclose  any  change  in  shape  or  size  of  the  pelvis,  indicate 
the  degree  of  the  defomiity,  and  thus  influence  the  treatment.  The 
measurements  are  made  externally  and  internally  between  certain 
bony  prominences.  The  varying  factors  in  the  external  measure- 
ments to  be  taken  into  consideration  are  the  thickness  of  the  skin, 
subcutaneous  tissue  and  the  bones. 

Estimation  of  the  Size  of  the  Inlet. — ^An  approximate  idea  of  the 
transverse  diameter  is  gained  by  measuring  externally  between  the 
anterior  superior  spinous  processes  of  the  ilia  (26  cm. ) ;  between  the 
crests  of  the  ilia  where  they  are  most  widely  separated  (29  cm.) ; 
between  the  two  trochanters  (31  cm.).  The  transverse  diameter 
may  be  determined  more  accurately  by  an  internal  measurement 
called  the  internal  ascending  ohlique  (Lohlein).  This  is  measured, 
by  the  finger  in  the  vagina,  from  the  centre  of  the  sub-pubic  liga- 
ment to  the  upper  anterior  corner  of  the  great  sacro-sciatic  foramen. 
The  transverse  is  2  cm.  longer  than  this  diameter. 

An  idea  of  the  length  of  the  antero-posterior  diameter  of  the  inlet 


PELVIMETRY.  75 

is  derived  from  the  external  conjugate^  measured  from  the  depression 
under  the  spine  of  the  last  lumbar  vertebra  to  the  upper  edge  of  the 
sjnmphysis  (20i  cm.).  The  internal  measurement  for  estimating  the 
antero-posterior  diameter  is  made  by  the  fingers  reaching  from  the 
middle  of  the  sub-pubic  ligament  to  the  top  of  the  promontory,  and 
is  called  the  iutermd  conjuffate  diarjonal  (12j  cm.).  This  diameter 
is  necessarily  longer  than  the  true  conjugate,  and  it  has  been  found 
that  by  substracting  If  cm.,  the  true  conjugate  is  estimated.  The 
possible  sources  of  eiTor  in  thus  estimating  the  true  conjugate  are 
found  in  the  fact  that  the  internal  conjugate  diagonal  does  not  take 
into  account  the  height  and  angle  of  the  symphysis,  two  factors  which 
obviously  influence  the  length  of  the  tme  conjugate,  while  they 
have  no  effect  upon  the  diagonal  conjugate.  Normally  the  height 
of  the  symphj^sis  is  4  cm.,  and  its  angle  105°  (conjugato-symphyseal 
angle). 

If  this  were  always  the  case,  subtracting  If  cm.  from  the  measured 
internal  conjugate  diagonal  would  be  absolutely  correct.  As  a 
matter  of  fact,  both  the  height  and  the  angle  vary,  and  by  the  follow- 
ing rules  the  true  conjugate  can  be  accurately  determined. 

For  every  .5  cm.  increase  in  the  height  of  the  symphysis  above  the 
normal,  add .  3  cm.  to  If  cm. ,  and  subtract  the  sum  fi"om  the  measured 
internal  conjugate  diagonal.  The  converse  of  this  is  applicable  to  a 
decrease  in  height  of  the  symphysis. 

For  every  degree  of  increase  of  the  conjugato-symphyseal  angle 
above  the  normal,  add  half  that  number  of  mm.  to  If  cm.,  and  sub- 
tract the  sum  from  the  measured  internal  conjugate  -diagonal.  The 
converse  of  this  is  also  true. 

The  oblique  or  diagonal  diameters  may  be  measured  externally 
from  the  posterior  superior  spinous  process  of  the  ilium  to  the  oppo- 
site anterior  superior  spine  (22  cm.). 

Estimation  of  the  Size  of  the  Cavity. — Xo  external  points  ofmeas- 
urement.  Its  general  size,  or  the  presence  of  a  tumor,  is  learned  by 
a  vaginal  examination. 

Estimation  of  the  Size  of  the  Outlet. — As  it  is  increased  in  many 
varieties  of  deformity,  and  but  rarely  contracted,  external  measure- 
ments are  not  required  in  the  vast  majority  of  cases.  It  is  decreased 
in  the  kyphotic  pelvis.  The  distance  between  the  tuberosities  of  the 
ischia  (11  cm.)  is  ascertained  by  Chantreuil's  method:  placing  the 


76  OBSTETRICAL  LECTURES. 

two  thumbs  on  tlie  tuberosities,  and  an  assistant  measures  the  dis- 
tance between  them. 

Chief  diagnostic  points  of  the  commoner  forms  of  pelvic  deformity^ 

Simple  Flat  Pelvis. — The  external  conjugate  will  be  less  than 
2O4  (19  or  18),  and  the  internal  conjugate  diagonal  less  than  12|. 

Flat  Rachitic— T\\Q  external  conjugate  lessened  (18  or  under). 
Internal  coujug.  diagonal  lessened  (11  or  under).  Conjugato-sym- 
physeal  angle  is  increased  ;  about  2  cm. ,  not  If  cm, ,  is  subtracted. 
The  relation  of  the  distances  between  the  spines  and  crests  is  dis- 
turbed. 

Jiisto-minor. — All  the  diameters  less,  but  normal  relation  main- 
tained. 

Justo-major. — All  diameters  increased,  but  normal  relation  re- 
mains. 

In  private  practice  it  is  by  no  means  necessary  to  accurately  meas- 
ure the  pelvis  of  every  pregnant  woman.  When,  however,  there 
exist  evidences  of  some  deformity,  as  rachitis,  kj^phosis,  coxalgia,  a 
history  of  grave  difficulty  in  previous  labors,  etc. ,  a  vaginal  examina- 
tion should  be  made  to  estimate  the  conjugata  vera,  and  other 
measurements  taken  as  maj?^  be  indicated. 


Foetometry. 

Table  of  Measurements. 

Child. 

Length 50  cm. 

Bisacromial 12  cm. 

Head. 

Biterap.... 8    cm. 

Bipariet 9^ 

Occip.  front llf 

Occip.  mental 13j 

Trachelo-bregm 9j 

Circumference,  occip. ,  front 34 J 

The  weight  of  mature  infant  is  3250  grm. 


In  connection  with  the  size  of  the  pelvis,  a  second  important  factor 


FOETOMETRY. — ANTISEPSIS.  77 

influencing  the  difficulty  of  labor,  is  the  size  of  the  foetus,  particularly 
of  its  head. 

Estimation  of  the  Size  of  the  Foe.tus. — An  approximate  idea  of  its 
size  can  be  determined  by  abdominal  palpation. 

Ahdoriiiiial  Palpation. — The  woman  should  be  placed  on  her  back, 
with  abdomen  exposed.  The  examiner,  standing  to  one  side  facing 
her  head,  by  a  series  of  stroking,  patting  and  rubbing  motions,  deter- 
mines the  height  of  the  fundus,  tension  of  abdominal  wall,  irritability 
of  the  uterus,  quantity  of  liquor  amnii,  size  of  the  foetus,  its  position 
and  presentation. 

Position  and  Presentation. — The  palmar  surface  of  the  tips  of  the 
fingers  are  carried  up  the  sides  of  the  abdomen,  and  upon  one  side 
(left  in  the  first  position)  is  noticed  firm,  broad,  even  resistance,  con- 
trasting with  the  cystic,  tumor-like  sensation  of  the  other  side. 

This  resistance  is  produced  by  the  back,  and,  to  confinn  thLs,  the 
extremities  are  searched  for  by  a  nibbing  motion  on  the  opposite 
side.  Having  located  the  back  and  the  extremities,  the  portion  of 
the  foetal  ellipse  presenting  at  the  superior  strait  is  next  ascertained. 

The  examiner  now  faces  the  woman's  feet,  and,  with  the  middle 
fingers  over  the  centre  of  Poupart's  ligament,  the  fingers  clip  down 
into  the  pelvic  cavity.  If  the  head  is  presenting,  it  is  felt  as  a  hard, 
round  mass.  At  the  same  time  its  density,  compressibility  and 
approximate  size  may  be  learned. 

When  it  has  not  engaged,  its  relative  size  to  the  inlet,  which  is  of 
obvious  importance,  may  be  discovered  by  an  efi'ort  to  push  it  through 
the  superior  strait. 

Antisepsis. 

Mortality  of  Septic  Infection. — In  large  cities  the  average  death 
rate  of  confinement  cases  is  about  one  per  cent. ,  the  greater  propor- 
tion being  due  to  septic  infection.  In  Philadelphia  about  thirty 
thousand  women  are  annually  confined  at  term,  and  of  these  between 
two  and  three  hundred  die  fi-om  septic  infection. 

Functions  of  Microbrganisms. — The  widespread  distribution  of 
microorganisms  is  now  well  known,  and  investigation  has  shown  then* 
chief  function  to  be  disintegrators  and  destroyers  of  dead  animal  and 
vegetable  matter. 

Ptomaines. — In  their  work  of  disintegrating  and  destroying  dead 


78  OBSTETRICAL  LECTURES. 

animal  matter,  poisonous  products  are  produced,  called  animal  alka- 
loids or  ptomaines  [irrcfia^  dead  body).  When  the  latter  are  absorbed, 
they  give  rise  to  various  pathological  and  clinical  manifestations, 
some  proving  fatal  to  animal  life,  others  causing  a  rise  of  tempera- 
ture, etc. 

Phenomena  Resulting  from  Microhe  Invasion. — The  cells  of  living 
matter  resent  their  invasion  and  a  struggle  for  supremacy  begins. 
By  their  higher  specialization  for  greater  resistance,  the  skin  and 
mucous  membranes  ordinarilj^  serve  as  barriers  to  their  entrance,  but 
if  these  are  passed,  the  more  delicate  and  less-resisting  cells  take  up 
the  combat.  The  result  is  largely  dependent  upon  the  extent  of 
invasion,  the  virulence  of  the  microbe,  and  the  individual  power  of 
resistance  of  the  living  cells. 

Invasion  in  Puerpera. — The  examining  hand  maybe  infected,  and 
through  the  placental  site  or  lacerations  of  the  parturient  canal  an 
entrance  into  the  general  system  is  effected.  A  fatal  result  in  every 
case  is  avoided,  in  two  ways :  As  a  rule,  the  examining  hand  is  not 
infected  with  the  particularly  viralent  varieties,  and  in  many  cases 
the  living  cells  are  able  to  resist  the  germs  that  may  have  gained 
access.  These  elements  of  safety  are  invalidated,  however,  by  the 
following  facts :  The  germs  that  may  have  been  introduced,  when  at 
their  work  of  disintegrating  the  dead  animal  matter,  as  clots,  shreds 
of  membrane,  deciduge,  etc. ,  grow,  multiply  and  increase  in  virulence, 
and  the  power  of  resistance  of  the  vital  cells  varies  in  different  indi- 
viduals. Therefore  it  is  impossible  to  predict  the  character  of  the 
germ  that  may  be  absorbed,  whether  virulent  or  otherwise,  and  in 
no  case  can  we  know  an  individual's  power  of  resistance.  With  so 
much  uncertainty  surrounding  every  case,  it  is  obviously  necessary 
to  apply  our  knowledge  of  germicides  and  endeavor  to  prevent  the 
introduction  and  further  development  of  microorganisms. 

TABLE  OF  COMPARATIVE  GERMICIDAL  POWER. 

BicMoride  of  Mercury  i 

Creolin / 

Thymol I  ^^ 

Benzoate  of  Sodium...  J  

Salicylic  Acid 3 

Carbolic  Acid  1 


ANTISEPSIS.  79 

The  bichloride  of  mercury  is  effective  but  dangerous.  Creolin.is 
probably  as  powerful  as  the  bichloride  ;  thus  far  has  been  found  much 
less  dangerous,  and  is  therefore  recommended. 

Application  of  Antt'seps-ls  to  Obstetrics. — The  advantages  of  anti- 
vseptic  precautions  in  obstetric  practice  have  been  clearly  demonstrated 
by  an  enormous  reduction  of  mortality  since  its  employment  has  be- 
come so  general.  At  one  time  in  the  Vienna  Hospital  the  mortality 
was  one  death  in  nine  cases  ;  now  it  is  .  3  per  cent.  In  the  Paris 
Maternite  it  has  been  10  per  cent.,  while  recently  in  the  same  hos- 
pital there  were  1000  cases  without  a  death.  At  the  Philadelphia 
Hospital  the  mortality  has  been  reduced  from  7  per  cent,  to  less  than 
1  per  cent.  Semmelweis,  the  originator  of  antiseptic  practice  in 
obstetrics,  accomplished  the  following  striking  reduction  in  mortality 
in  his  hospital  by  requiring  students  to  disinfect  themselves  before 
attending  the  cases  : — 


Year. 

Confinements. 

Deaths. 

Per  Cent. 

1846 

4010 

459 

11.4 

1847 

3490 

.    176 

5. 

1848 

3556 

45 

1.27 

Antisepsis  in  Hospital  Practice, 

{a)  Disinfection  of  the  Patient. — When  the  signs  of  beginning 
labor  manifest  themselves,  the  patient  should  receive  a  bath  and  be 
supplied  with  clean  clothes.  After  labor  is  completed  the  vagina 
should  receive  one  douche  of  2  per  cent,  solution  of  creolin  by  means 
of  a  fountain  syringe,  preferably  of  glass,  the  vaginal  tube  also  of 
glass,  with  lateral  perforations.  If  an  intrauterine  injection  be  re- 
quired, the  glass  tube,  a  two-way  metal  catheter  or  stiff  rubber  cath- 
eter, may  be  used,  jDreferably  with  a  fountain  syringe . 

(b)  Disinfection  of  the  Bed. — The  lying-in  bed  should  contain  the 
following  :  1,  a  pad  about  a  yard  square,  composed  of  an  upper  layer 
of  flannel,  a  piece  of  blanket  and  a  layer  of  mackintosh,  all  to  be 
soaked  in  bichloride  solution,  1  to  2000,  before  using ;  2,  a  sheet 
covering,  3,  a  rubber  blanket ;  4,  a  second  sheet,  and  under  this,  5, 
another  rubber  cloth,  to  protect  the  mattress. 

(c)  Disinfection  of  the  Attendants. — The  hands  and  wrists  of  doctor 
and  nurse  washed  in  warm  water  with  soap  and  brush  ;  nails  pared 
and  cleaned  ;  hands  and  wrists  rinsed  in  alcohol  and  placed  in  bichlo- 


80  OBSTETRICAL  LECTURES. 

ride  solution.  1  to  1000,  for  at  least  one  minute,  after  which  they 
should  not  be  dried  on  septic  towels,  etc. 

{d)  Disinfection  of  Instruments. — If  not  easily  corroded,  soaked 
in  bichloride  solution,  1  to  1000 ;  otherwise,  use  5  per  cent,  solution 
carbolic  acid.  This  applies  to  all  instniments  used  in  vagina,  urethra 
or  rectum. 

Protection  after  Lahor. — The  pads  which  receive  the  lochia  should 
be  changed  six  times  in  twenty-four  hours  for  three  days,  and  less 
frequently  subsequently  as  may  be  needful.  Protect  the  parturient 
tract  from  invasion  by  the  occlusive  dressing.^  composed  of  three  or 
four  layers  of  sublimated  gauze  (boat-shaped)  upon  waxed  paper, 
and  corrosive  cotton  upon  this  to  protect  vulvar  opening.  This 
dressing  to  be  changed  si:x,  seven  or  eight  times  daily  for  the 
first  three  days  and  less  frequently  aftei-ward.  When  changed,  the 
external  genitalia  should  be  washed  several  times  daily  with  baked 
cotton  and  bichloride  solution  1  to  2000. 

Antisepsis  in  Private  Practice. 

The  patient,  nurse,  clothing,  etc,  are  usually  sufficiently  clean. 
Avoid  infecting  the  patient  by  thorough  personal  disinfection  of 
doctor,  nurse  and  instniments.  An  occlusive  dressing  should  be 
used  to  prevent  infection  fi'om  the  atmosphere.  The  lying-in  room 
should  not  contain  a  stationary  washstand  nor  be  in  close  proximity 
to  water  closet.     An  open  fireplace  is  desirable. 

Diagnosis  of  Pregnancy. 

Subjective  Signs. — Arranged  in  the  order  of  their  relative  import- 
ance. 

{A)  Cessation  of  Menstruation. — Is  the  most  valuable  of  the  subjec- 
tive signs,  but  is  not  always  to.be  depended  upon.  It  may  occur  inde- 
pendently of  pregnancy,  in  immigrants  experiencing  a  sudden  change 
in  climate  ;  in  various  mental  disorders,  as  hj^steria,  mania  ;  as  the  re- 
sult of  old  peri-uterine  inflammation  ;  it  often  accompanies  phthisis. 

In  i^regnancj^  the  menstrual  discharge  may  occur  during  the 
first  three  months.  Sometimes  this  may  be  due  to  failure  of  union 
of  the  deciduje.  Rarely  it  may  continue  throughout  the  whole 
period  of  gestation. 


DIAGNOSIS   OF   PREGNANCY.  81 

{B)  Nausea  and  Vomiting. — Are  reflexly  as.sociated  with  the  de- 
veloping foetus,  and  occur  usually  at  the  6th  or  7th  week.  They 
may  occur  reflexly  from  other  conditions,  as  a  displaced  utems,  an 
organ  which  is  badly  inflamed,  congestion  or  inflammation  of  the 
tubes  and  ovaries,  growing  tumors  within  the  pelvic  cavity,  etc. 
They  may  be  altogether  absent,  yet  rarely  in  some  individuals  they 
appear  so  early,  and  with  such  promptness  and  regularity,  as  to  con- 
stitute a  most  valuable  sign. 

{C)  Changes  due  to  Increased  Blood  Supply  to  the  Genitalia  and 
Breasts. — These  are  tingling  and  a  sensation  of  fullness  in  the  breasts, 
with  the  development  of  colostrum  ;  leucorrhcea  ;  increased  temi^era- 
ture  of  the  genitalia.     Are  of  comparatively  little  value. 

{D)  Quickening . — Is  the  sensation  experienced  by  the  mother  as 
the  result  of  foetal  movements,  and  usually  first  appears  between  the 
fourth  and  fifth  months. 

{E)  Alterations  in  the  Nervous  System. — Changes  in  disposition, 
mental  peculiarities,  perversions  of  taste. 

Objective  Signs. — Are  of  much  more  importance  and  value.  Are 
obtained  by  employing  the  senses  of  sight,  touch  and  heanng. 

{A)  Inspection. 

(a)  Face. — Chloasmata,  splotches  of  ii'regular  pigmentation  on 
brow  and  cheeks.  Development  of  the  dark  ring  under  the  eyes. 
(b)  Breasts. — Enlarged;  veins  distended  and  tortuous  ;  nipple  promi- 
nent ;  deposition  of  pigment — widening  the  areola  and  developing 
the  secondary  areola.  Enlargement  of  the  glands  of  Montgomery  ; 
presence  of  colostrum.  All  these  signs  can  be  manifested  inde- 
pendently of  pregnancy,  and  rarely  may  be  absent,  (c)  Abdomen. — 
Is  pear-shaped.,  with  the  narrow  end  downward  ;  tumor  is  situated 
in  the  median  line,  spreading  with  approximate  equality  to  either 
side.  Strige  are  present.  The  umbilicus  at  the  sixth  month  is  level 
with  the  surface  of  the  abdomen  and  later  pouts.  It  is  suiTOunded 
by  a  ring  of  pigmentation  which  spreads  above  and  below  along  the 
linea  alba. 

Foetal  movements  can  be  seen  if  the  pregnancy  be  far  advanced. 
In  the  latter  months  the  mucous  membrane  of  vagina  and  vulva  are 
violet  or  purple. 

{B)  Touch. —  {a)  Abdomincd  palpation.  By  this  method  is 
learned  the  size  and  shape  of  the  uterus  ;  in  advanced  cases,  the 
6 


82  OBSTETRICAL  LECTURES. 

position  of  the  foetal  back,  head  and  extremities  ;  the  intermittent 
uterine  contractions  (Braxton  Hicks) ;  foetal  movements. 

Braxton  Hicks'  sign  is  available  by  the  last  of  the  third  month, 
and  although  it  may  be  produced  by  any  tumor  which  sufficiently 
distends  the  uterine  wall,  as  a  collection  of  blood,  soft  fibroma,  etc., 
it  is  almost  a  positive  sign.  Foetal  movements  are  absolutely  diag- 
nostic. 

(6)  Combined  examination. — (1)  Softened  cervix. — A  ready  rule 
of  practice  is,  that  "  when  the  cervix  is  as  hard  as  one's  nose,  preg- 
nancy does  not  exist;  when  soft  as  one's  lips,  pregnancy  is  prob- 
able "  (Groodell).  Bapidly-growing  myomata,  acute  metritis,  haema- 
tometra,  can  thus  simulate  pregnancy  by  softening  the  cervix. 
(2)  Hegar's  sign.  This  is  a  softening  of  the  lower  uterine  segment, 
which  is  situated  between  the  cervix  and  the  upper  uterine  segment. 
Can  be  elicited  by  the  forefinger  in  the  rectum,  thumb  in  the  vagina, 
and  pressure  on  the  fundus  above.  (3)  EnlargemenUof  the  uterus. 
In  the  early  months  deposition  of  lymph  upon  the  uteiTis  may  lead 
to  an  error  in  diagnosis.  (4)  BaUottement.  With  one  hand  over 
the  fundus,  and  the  fingers  of  the  other  in  the  vagina,  an  impulse 
is  communicated  to  the  contents  of  the  uterus  by  the  vaginal  hand, 
when  the  foetus  will  be  felt  to  strike  the  fundus,  and,  returning,  will 
impinge  upon  the  vaginal  hand.  This  is  a  positive  sign,  and  is 
available  in  the  fourth  month.  A  small  cystic  tumor  of  the  ovary, 
with  a  long  pedicle  and  an  extra-uterine  gestation,  are  possible  sources 
of  error. 

(C)  Hearing. — {a)  Foetal  heart  sounds.  Rate,  120  to  160  per 
minute.  Available  in  the  fifth  month.  The  third  positive  sign. 
Are  to  be  distinguished  from  the  pulsations  of  the  abdominal  aorta. 
The  area  of  their  maximum  intensity  in  anterior  positions  of  the 
vertex  is  an  inch  below  the  umbilicus,  to  the  left  or  right ;  in  poste- 
rior positions,  in  the  flanks,  on  a  line  which  passes  through  the 
umbilicus.  Their  absence  does  not  exclude  the  existence  of  preg- 
nancy,    (b)  Dullness  on  percussion. 

Chnically,  the  signs  of  pregnancy  may  be  divided  into  three 
trimesters  of  three  months  each. 

The  Isf. — Will  manifest  the  following  signs  :  enlargement  and 
bogginess  of  the  uterine  body ;  soft  cervix  ;  enlargement  of  the 
breasts  ;  nausea  ;  Hegar's  sign  ;  cessation  of  menstruation. 


PHYSIOLOGY   OF   PREGNANCY.  83 

The  2d. — In  addition  to  above,  Braxton  Hicks'  sign  ;  feeble  foetal 
movements  ;  ballottement ;  heart  sounds. 

The  3d. — All  the  above  present  to  a  greater  degree. 

Estwiation  of  the  Duration  of  Pregnancy. — Ordinarily  the  cessa- 
tion of  menstruation  is  depended  upon.  A  convenient  rule  for  pre- 
dicting the  date  of  confinement  is  to  "count  back  three  months 
from  the  date  of  appearance  of  the  last  mensti-ual  flow,  and  add 
seven  days  "  (Naegele).  An  approximate  idea  maj"  also  be  gained 
by  noting  the  height  of  the  fundus  : — 

4th  month,  midway  between  umbilicus  and  symphysis. 

6th  month,  on  a  level  with  the  umbilicus. 

7th  month,  midway  between  umbilicus  and  xyphoid. 

8th  month,  at  the  xyphoid. 

9th  month,  descends  almost  to  the  depth  at  which  it  was  at  the 
7th  month. 

Diagnosis  of  Life  or  Death  of  the  Foetus. — The  foetal  heart  sounds 
are  the  most  valuable  sign  when  heard. 

Diagnosis  of  the  Situation  of  the  Developing  Ovum. — Whether 
intra-  or  extra-uterine  (see  Extra-uterine  Pregnancy). 

Diagnosis  of  a  Prior  Pregnancy. — Of  medico-legal  value,  (a) 
Cervix  lacerated,  usually  laterally,  {b)  Cervical  canal  irregularly 
enlarged,  usually  admitting  first  joint  of  index  finger. 


Physiology  of  Pregnancy. 

Alterations  in  organs  and  tissues  in  consequence  of  pregnancy. 

(A)  Local  Changes. 

I.  Uterus. 
{a)  Devehjjment  of  Constituent  Parts. — 1.  Muscle.     Fibres  hyper- 
trophied  eleven  times  as  long,  five  times  as  broad  as  those  of  the 
non-pregnant  uteras.     The  theorj^  of  an  additional  hyperplasia  of 
these  structures  has  never  been  actually  demonstrated. 

2.  Connective  tissue.     Increased  chiefly  by  absorption  of  fluid  and 
consequent  increase  in  bulk. 

3.  Peritoneal    covering.     Increased    by   both    hypertrophy   and 
hyperplasia  of  the  constituent  elements. 


84  OBSTETRICAL  LECTURES. 

4.  Blood  vessels.  Arteries  increase  in  calibre,  length  and  tortu- 
osity. Veins  grow  to  a  very  large  size ;  their  covering  is  reduced 
to  the  iutima.  They  are  surrounded  by  the  uterine  muscle,  which 
obliterates  them  after  labor. 

5.  Nerves.  Increased  more  by  a  development  of  the  connective 
tissue  about  them  (neurolemma)  than  by  an  increase  of  the  nerve 
elements. 

6.  Lymphatics.  Increased  by  hypertrophy  and  hyperplasia.  The 
lymph  spaces  below  the  uterine  mucous  membrane  are  enormously 
enlarged,  and  the  lymph  tubes  leading  from  them  through  the 
uterine  muscles  reach  the  size  of  a  goose  quill.  These  lymph  tubes 
or  vessels  are  collected  in  a  plexus  beneath  the  peritoneum,  which 
is  continuous  with  the  general  lymphatic  system. 

This  arrangement  and  development  explain  the  remarkably  rapid 
absorption  of  the  uteiTis  after  labor,  and  accounts  for  the  ready 
absorption  of  infecting  material,  with  peritonitis  oftentimes  as  an 
early  symptom. 

(6)  Anatomy  of  the  Uterus  at  Full  Term.  — The  muscle  fibres  of 
the  non-pregnant  utei'us  have  a  very  irregular  distribution.  In  the 
pregnant  womb  three  layers  may  be  distinguished — an  outer,  middle 
and  internal  layer.  The  outer  is  continuous  with  the  muscular  fibres 
in  the  round  ligaments  and  tubes,  and  is  mainly  longitudinal  in 
aiTangement.  The  middle  layer  is  composed  of  bundles,  which  pass 
from  their  peritoneal  attachment  obliquely  downward  and  inward  to 
be  attached  to  the  submucous  tissue.  Above  the  ' '  contraction  ring ' ' 
this  oblique  arrangement  is  less  marked,  while  below  it  is  more  pro- 
nounced. The  internal  layer  is  thin  and  poorly  developed,  except 
at  definite  points.  Its  arrangement  is  chiefly  circular,  and  is 
specially  developed  at  the  openings  of  the  tubes  and  internal  os. 

(c)  Changers  in  Volume,  Capacity  and  Weight. — Before  impreg- 
nation, the  length  of  the  uterine  cavity  is  about  2  J  inches  ;  at  term, 
it  is  increased  to  12  inches,  while  its  breadth  is  9  inches  and  depth  8 
inches.  The  capacity  changes  from  1  cubic  inch  to  400  cubic  inches, 
weight  from  about  2  ounces  to  2  pounds. 

{d)  Changes  in  Form.,  Position  and  Topographical  Relations. — 
From  flattened  pyriform  to  spherical,  and,  finally,  ovoidal.  During 
the  early  months  the  position  of  the  uterus  is  altered  by  sinking 
into  the  pelvic  cavity,  as  a  result  of  the  increased  weight.     After 


PHYSIOLOGY  OF  PREGNANCY.  85 

the  third  month  it  rises  until  it  is  almost  in  contact  with  the  dia- 
phragm, and  before  term  (four  weeks  in  primiparse,  ten  days  or  one 
week  in  multiparas)  sinks  again  into  the  pelvic  cavity,  owing  to  the 
engagement  of  the  lower  portion  of  the  uterus  with  the  contained 
presenting  part  of  the  foetus  within  the  pelvic  canal. 

After  the  third  month,  the  laxity  of  the  abdominal  wall  allows  it 
to  fall  foi-ward.  In  consequence  of  the  position  of  sigmoid  flexure 
and  rectum,  it  is  slightly  tilted  to  the  right  and  rotated  on  its  longi- 
tudinal axis.  The  topographical  relation  of  the  intestines  is  impor- 
tant. They  are  alwa3^s  situated  above  and  behind  the  uterus,  thus 
giving  no  resonance  over  the  anterior  abdominal  wall. 

II.  Alterations  in  the  Cervix. 

Is  softened,  but  its  canal  is  undilated  until  the  first  stage  of  labor 
is  well  advanced. 

III.  Alterations  in  Yagina  and  Vulva. 

Changes  due  to  increased  blood  supply,  as  noticed  in  enumerating 
the  signs  of  pregnancy,  as  darkened  color,  increased  secretion  and 
over-development  in  the  muscular  and  mucous  walls. 

TV.  Pelvic  Joints. 

Loosening  of  their  connections  and  increase  in  motility,  thus  facili- 
tating the  passage  of  the  foetal  body. 

Y.  Abdominal  Walls. 

(a)  Stretching  of  all  the  constituent  parts^  with  the  formation  of 
striae,  resulting  from  cracks  in  the  subcutaneous  connective  tissue 
and  deeper  laj^-ers  of  the  skin. 

Q))  Separation  of  the  recti  muscles. — Exceptionally,  the  abdom- 
inal contents  may  be  extraded. 

(c)  Inci'eased  deposition  of  fat,  as  in  other  parts  of  the  body. 
This  is  probably  nature's  provision  for  sustaining  the  woman  during 
the  first  few  days  of  the  puerperium. 

YI.  Bladder  and  Rectum. 

The  growth  of  the  pregnant  uterus  mechanically  interferes  with 
their  functions,  hence  irritability  of  the  bladder  and  constipation  are 


86  OBSTETRICAL  LECTURES. 

frequent.  By  interfering  witli  their  blood  supply,  liemorrhoids  may 
develop,  not  only  of  tlie  anus  and  rectum,  but  of  the  bladder  as  well, 
which  rarely  give  rise  to  hemon-hage. 


(B)  Changes  in  the  Several  Systems  of  the  Body.    General 

Changes. 

I.  Circulatory  System. 

(a)  Blood. — Whole  quantity  increased.  Water  and  fibrin-making 
elements  increased ;  red  corpuscles  relatively  diminished ;  haemo- 
globin diminished ;  white  corpuscles  actually  and  relatively  increased. 

(h)  Heart. — Left  side  said  to  hypertrophy,  and,  in  consequence  of 
unusual  determination  of  blood  to  the  brain,  there  is  developed  on 
the  inner  table  of  the  skull  new  formations  of  bone,  called  osteo- 
phytes. 

II.  Urine. 

Becomes  more  watery  ;  specific  gravity  diminished  ;  quantity  of 
urea  normal.  The  kyesteinic  pellicle  is  no  longer  regarded  of  any 
diagnostic  value. 

III.  Digestive  System. 

Nausea  and  vomiting  ;  torpor  of  intestines  and  rectum,  inducing 
constipation. 

ly.  Nervous  System. 

Alterations  in  disposition  ;  perversions  of  taste ;  disposition  to 
melancholia  ;  severe  neuralgias,  esioecially  of  the  face  and  teeth. 

y.  Changes  in  Weight. 

An  increase  of  y^  part  of  the  original  body  weight  (G-assner). 
This  estimate  is  not  uniformly  correct,  as  irregularities  are  frequently 
met  with. 

yi.  Changes  in  the  Respiratory  Apparatus. 

Lungs  are  shorter  but  broader,  leaving  the  capacity  unchanged  ; 
alterations  in  the  expired  air  of  no  clinical  importance. 


PATHOLOGY  OF  PREGNANCY.  87 

Pathology  of  Pregnancy. 

I.  Diseases  of  the  Genitalia. 

1.  Displacements  of  the  Pregnant  Uterus.— It  may  be  dis- 
placed forward,  backward,  to  either  side,  downward.  It  may  form 
part  of  the  sac  contents  in  inguinal  and  ventral  hernia,  and  may  be 
twisted  upon  the  cervix. 

(a)  Anteflescion. —LhuoWy  the  growth  of  the  utenis  replaces  the 
organ  spontaneously,  but  when  bound  down  by  bauds  of  adhesive 
inflammation,  pain  and  difficulty  in  urination  result,  until  finally 
the  uterus  expels  its  contents,  or  forces  its  way  up  into  the  abdomi- 
nal cavity. 

Treatment.— M^sssige,  and  efi'orts  to  replace  it  through  the  vaginal 
vault.  Late  in  gestation  the  whole  body  of  the  uterus  may  fall 
forward  in  consequence  of  greatly  relaxed  abdominal  walls  or  separa- 
tion of  the  recti  muscles,  producing  a  pendulous  abdomen.  Treated 
by  abdominal  binder. 

(6)  Retroflexion  or  Retroversion. — Of  rather  frequent  occurrence. 
Explained  almost  invariably  by  the  previous  existence  of  such  a 
displacement. 

Symptoms.— The  earhest  and  most  distinctive  is  dysuria,  which 
should  lead  to  a  vaginal  examination  to  confirm  the  diagnosis.  In 
neglected  cases,  or  where  nature  has  not  corrected  the  displacement 
spontaneously,  incarceration  occurs.  The  symptoms  of  this  manifest 
themselves  after  the  third  month,  and  are  :  occlusion  of  the  bowel 
and  urethra,  with  their  associated  symptoms  ;  congestion,  inflamma- 
tion and  suppuration  of  the  uterus,  which  may  finally  slough  with 
the  development  of  peritonitis  and  septic  infection. 

Terminations  when  Artificial  Means  are  not  Emjohyecl. — Sponta- 
neous replacement ;  spontaneous  abortion  ;  expulsion  of  the  uterus 
from  the  body  as  a  whole  ;  rarely  by  sacculation  of  the  utems. 

Prognosis. — Always  satisfactory  as  regards  maternal  life  when 
treatment  is  adopted  early. 

Treatment.— KdYAd^atmewt.  If  undertaken  early,  manual  means, 
pressing  fundus  in  the  direction  of  one  or  the  other  sacro-iliac  joints, 
the  patient  in  the  lithotomy  position.  Failing,  resort  to  knee-chest 
posture  and  a  repositor  to  press  upon  the  fundus.      The  cervix 


50  OBSTETRICAL  LECTURES. 

should  next  be  drawn  downward  with  tenaculum,  at  the  same  time 
continuing  the  efforts  to  replace  the  fundus.  If  successfal,  a  large 
sized  pessary  or  tampon  should  be  applied  until  the  growth  of  the 
organ  maintains  it  in  the  abdominal  cavity.  When  bound  down  by 
strong  inflammatory  bands,  steady  and  long-continued  pressure 
should  be  supplied  by  large  tampons  in  the  posterior  vaginal  vault. 
Failing,  finally,  abortion  should  be  induced. 

Treatment  when  Incarcerated. — Attempts  at  reposition  as  above. 
These  unavailing,  as  is  usual,  induce  abortion.  If  it  is  impossible  to 
effect  an  entrance  into  the  cervix  for  this  purpose,  it  is  justifiable 
to  puncture  the  uterine  wall  through  the  vaginal  vault,  and  thus 
draw  off  the  liquor  amnii.  The  organ  may  now  respond  to  efforts 
at  replacement,  or  permit  the  cervix  to  be  drawn  down  and  its 
canal  dilated,  to  accomplish  the  evacuation  of  its  contents.  If  the 
bladder  is  seriously  distended  it  should  be  emptied  by  the  urethra, 
or  supra-pubic  puncture  with  an  aspirating  needle  may  be  necessary. 
As  a  last  resort,  vaginal  hysterectomy  is  justifiable. 

(c)'  Displacements  to  Either  Side. — Include  latero- position,  latero- 
version,  latero-flexion.  Latero-position  is  usually  a  congenital  defect 
due  to  abnormally  short  broad  ligaments,  placing  the  whole  uterine 
body  more  to  one  side  of  the  abdominal  cavity.  Latero-flexion  is 
also  congenital,  due  to  imperfect  development  of  one  side  of  the 
uterine  body.  These  malpositions  complicate  labor  more  than  preg- 
nancy (see  Dystocia). 

{d)  Prolapse. — Causes. — Impregnation  in  an  organ  already  pro- 
lapsed, or  the  consequence  of  retroversion,  relaxed  vaginal  walls  and 
outlet ;  the  increased  weight  leads  to  prolapse  in  the  first  few  weeks 
of  ]jregnancy. 

Terminations. — (1)  Complete  spontaneous  reposition,  which  is  most 
frequent.  (2)  Incomplete  reposition,  continuing  in  that  state  to 
fall  term,  (3)  Failure  of  retraction,  inducing  incarceration.  (4) 
Failure  of  retraction,  inducing  abortion.  Pregnancy  will  not  con- 
tinue to  term  in  a  completely  prolapsed  organ. 

Treatment.— KQ^osiiion  and  application  of  some  variety  of  baU 
pessary,  retained  by  a  firm  T-bandage.  When  incarcerated,  attempts 
at  reposition  should  be  cautious,  but  if  they  fail,  owing  to  adhesions 
and  oedema,  abortion  should  be  induced  and  the  organ  replaced. 

(e)   The  Pregnant  Uterus  forming  a  Part  of  a  Hernial  Protrusion. 


PATHOLOGY  OF  PREGNANCY.  89 

— Occurs  exceptionally,  in  inguinal  and  ventral,  but  never  in  crural 
hernia,  the  uterus  getting  into  the  sac  before  or  after  impregna- 
tion. The  ventral  variety  is  most  frequent,  and  may  occur  between 
abnormally  separated  recti  muscles,  or,  more  rarely,  is  seen  on  the 
lateral  aspect  of  the  abdomen.  When  it  occurs  in  the  very  excep- 
tional inguinal  variety,  the  pregnancy  is  apt  to  be  in  one  horn  of  an 
abnormally  developed  uterus. 

Treatment. — Attempts  at  reposition.  These  failing,  entering  the 
hand  in  the  uterus,  version  and  extraction  are  to  be  considered.  The 
last  resort  is  Caesarean  section  or  amputation  of  the  pregnant  uterus. 

(/)  Torsion. — kSlight  degree  of  torsion  from  left  to  right,  phj^sio- 
logical  and  constant.  A  more  exaggerated  degree  may  be  due  to 
some  abnormal  condition,  usually  inflammatory,  near  the  uterus,  • 
which  results  in  twisting  it  upon  its  longitudinal  axis.  An  ovary 
may  thus  be  brought  in  front  and  be  subjected  to  traumatism  during 
manipulation  of  the  abdomen. 

2.  Diseases  of  the  Uterine  Muscle. — («)  Bheumatism. — 
Most  common  ;  occurs  in  those  of  rheumatic  diathesis. 

Symptoms. — Great  pain,  localized  in  the  uterine  walls,  lasting 
throughout  the  latter  months  of  pregnancj^  and  increased  periodic- 
ally by  the  intermittent  uterine  contractions.  The  therapeutic  test 
is,  perhaps,  the  most  valuable  factor  in  the  diagnosis. 

Treatment. — Administration  of  salicylate  of  sodium. 

(6)  Metritis. — Is  almost  invariably  acquired  before  impregnation, 
exercises  a  most  deleterious  influence  upon  gestation,  and  usually 
results  in  abortion. 

Symptoms. — When  pregnancy  continues,  there  is  great  pain,  a 
feeling  of  weight  and  heaviness,  and  usually  distressing  and  obstinate 
vomiting,  which,  in  some  cases,  may  indicate  the  induction  of  abor- 
tion. 

Treatment. — Glycerine  tampons  maybe  tried,  although verj^ likely 
to  induce  abortion. 

(c)  Neio  Growths. — Complicate  labor  more  than  gestation. — 1. 
Fibroids — are  the  most  frequent,  grow  rapidly,  and  in  exaggerated 
cases  some  operative  interference  is  demanded.  The  same  is  true  of 
other  i:)elvic  tumors  to  a  less  degree,  as  (2)  ovarian  cysts. 

3.  Malformations  of  the  Uterus.— -Complicate  labor  more 
than  gestation  (see  Dystocia). 


90  OBSTETRICAL  LECTURES. 

4.  Diseases  of  the  Cervix. — The  same  may  be  said  of  these, 
except  bad  cases  of  laceration  and  eversion  and  carcinoma,  which 
very  frequently  induce  abortion  or  premature  labor.  Minor  com- 
plications may  arise  from  inflammatory  processes  within  the  cervical 
canal,  giving  rise  to  mucous  or  even  bloody  discharges.  Supposed 
menstruation  i^ersisting  throughout  i^regnancy  is  probably  thus 
accounted  for. 

5.  Diseases  of  the  Vagina. — Due  to  increased  blood  supply  or 
specific  infection,  (a)  Leucorrhoea :  feeling  of  heat  and  discomfort, 
(b)  Specijic  infection.  Affects  rather  the  newborn  infant  and 
mother  soon  after  delivery.  Requires  energetic  treatment  to  elimi- 
nate such  complications.     Bichloride  douche,  1  to  2000  b.  d.,  and  a 

■  tampon  dusted  with  tannic   acid,     (c)    Hemorrlioids.     Gruard  the 
part  from  traumatism,  which  can  jiroduce  alarming  hemorrhage. 

6.  Diseases  of  the  Yulva. — Also  largely  due  to  increased 
blood  supply,  {a)  Hemorrlioids.  (Jb]  Vegetations.  Require  no  treat- 
ment beyond  protection,  (c)  Pruritus  vidvce.  May  be  a  neurosis, 
or  due  to  the  vaginal  and  cervical  discharges.  Is  oftentimes  in- 
tractable.    Treatment  belongs  to  gynaecology. 

7.  Peri-uterine  Inflammation  and  Adhesions. — May  be 
benefited  by  massage.  Appropriate  treatment  during  the  inteiTals 
between  pregnancies  is  required. 

8.  Loosening  of  Pelvic  Joints. — When  pronounced,  interferes 
with  locomotion.  The  diagnosis  is  made  by  a  vaginal  examination, 
the  patient  in  the  erect  posture  taking  a  few  steps.  Treatment : 
Application  of  a  firm  binder  about  hips  and  pelvis,  or  rest  in  bed  if 
exaggerated. 

9.  Breasts. — (a)  Mammary  Abscess.  Its  cause,  course  and  treat- 
ment same  as  when  it  occurs  during  the  puerperium.  (b)  Eczema 
of  the  Nipples.  Is  very  obstinate  and  resists  treatment.  Relief  only 
occurs  after  delivery. 

II.  Diseases  of  the  Alimentary  Canal. 

1.  Mouth. — (a)  Canes  of  the  Teeth. — Is  of  rather  common 
occurrence,  particularly  in  the  upper  classes.  As  a  rule,  it  is  best 
not  to  advise  interference,  as  dental  operations  might  provoke 
abortion. 

(b)    Toothache. — Develops  with    or  without    other    pathological 


PATHOLOGY  OF  TREGNANCY.  91 

changes  in  the  mouth,  and  resists  treatment.  Usually  subsides  when 
pregnancy  has  advanced  beyond  the  first  half  of  gestation. 

(c)  Ptyalhm. — Cause  not  known.  Astringents,  etc,  may  be 
employed.     Disappears  usually  in  the  latter  months. 

2.  Stomach. — Pernicious  Vomiting. —  Causes. — (l)Ileflexly,  from 
irritation  of  the  uterus  and  its  contained  nerve  endings  by  the 
stretching  of  the  uterine  walls.  It  is  thus  more  common  in  primi- 
parae,  and  when  chronic  metritis  or  displacement  of  the  uterus 
exists.  (2)  Inflammation  of  the  lining  membrane.  (3)  Engorgement 
of  neighboring  organs,  as  inflamed  tubes  or  ovaries.  (4)  Some  patho- 
logical condition  of  the  stomach,  as  chronic  gasti'itis,  gastric  ulcer, 
etc,  pregnancy  increasing  the  irritability  already  present.  (5)  Rarely 
some  pathological  condition  of  the  intestinal  tract.  (6)  Increased  in- 
dulgence in  sexual  intercourse.     The  latter  is  a  not  infrequent  cause. 

Diagnosis.  — Of  the  cause  is  difficult ;  of  the  condition  easy.  There 
is  fever,  great  emaciation  and  loss  of  strength,  which  maj^  prove 
fatal.     The  worse  cases  occur  between  the  second  and  fourth  months. 

Treatment. — Remove  the  cause,  if  ascertainable. 

(a)  Hygienic. — Includes  regulation  of  the  diet,  etc.  Advise  a 
light  breakfast  of  tea  and  bread  or  milk,  taken  in  bed  before  getting 
up,  the  patient  lying  flat  upon  her  back.  Sexual  intercourse  should 
be  restrained.  Oftentimes  there  is  improvement  when  the  sensation 
of  swallowing  is  removed  by  a  cocaine  spray  or  oesophageal  tube. 
Rectal  alimentation  in  extreme  cases,  the  enemata  being  non- irritat- 
ing, so  as  not  to  provoke  an  exhausting  diarrhoea.  The  ' '  rest  cure, ' ' 
combined  with  other  treatment,  has  proved  efficient  in  some  cases. 
Some  tolerance  of  the  stomach  may  at  times  be  established  by  allow- 
ing apparently  unsuitable  articles  of  food  when  specia%  desired  by 
the  patient. 

(b)  Medicinal.  — The  drugs  that  have  been  used  are  innumerable. 
Nervous  sedatives,  as  bromides,  chloral  and  opium,  are  the  most 
reliable.  Sodium  bromide,  gr.  x,  in  aq.  camph.,  3iv,  four  times  a 
day.  If  necessary,  resort  to  enemata  of  sodium  or  potassium  bro- 
mide, gr.  xl,  and  chloral,  gr.  xx,  two  or  three  times  a  day,  dissolved 
in  water. 

(c)  Gynaecological. — Replace  a  displaced  uterus.  If  the  cervix  or 
canal  is  inflamed,  api^ly  with  a  cylindrical  speculum  a  20-gr.  solution 
of  nitrate  of  silver.     If  api)lications  in  the  canal  are  used,  abortions 


92  OBSTETRICAL  LECTURES. 

may  result.  When  due  to  metritis,  treatment  does  not  accomplish 
much  at  this  time.  Grlj^cerine  tampons  may  be  used  after  simpler 
plans  fail,  as  they  may  induce  abortion.  Empirically,  a  15  per  cent, 
solution  of  cocaine  may  be  applied  to  cendx  and  vaginal  vault,  and, 
similarly,  dilatation  of  the  cervix  with  the  fingers  has  been  successful 
in  certain  cases. 

{d)  Obstetrical — Induction  of  abortion  or  premature  labor ;  should 
be  done  as  the  last  resort,  and  yet  not  too  late. 

3.  Intestines. — (a)  Constipation. — Should  be  guarded  against  to 
prevent  overwork  of  the  kidneys.  Cascara  sagrada,  the  weaker 
mineral  waters  and  pulv.  glycyiThizae  corap.  may  be  used.  Active 
purges  may  interrupt  the  course  of  gestation. 

R.     Ext.  cascarse  sagradse  gr.  j-ij. 

Confection  sennse gr.  x-xx. 

(h)  Diarrhaa. — When  the  ordinary  remedies  fail,  nerve  sedatives 
may  control  it,  as  it  is  sometimes  explained  by  intestinal  irritability, 
resulting  from  pressure  of  the  gravid  womb. 

4.  Liver. — Jaundice  may  result  from  a  mild  catarrhal  condition  of 
the  bile  ducts,  which  may  have  existed  before  pregnancy.  This  class 
of  cases  is  of  little  clinical  importance.  It  should  be  remembered 
that  a  serious  condition  may  develop  as  the  result  of  excessive  work 
thrown  upon  the  liver — namely,  an  acute  degeneration  of  the  whole 
hepatic  stmcture.  Another  explanation  is  that  poisons  (such  as  may 
produce  eclampsia)  circulating  in  the  blood  act  ujDon  the  liver,  pro- 
ducing acute  yellow  atrophy. 

Treatment. — The  simple  catarrhal  jaundice  is  treated  by  regulation 
of  diet  and  bowels,  and  securing  a  free  discharge  of  bile. 
The  graver  form  is  rapidlj^  fatal. 

5.  Hemorrhoids — Guard  against  constipation.    Astringent  appli-  - 
cations  may  be  made.     Operative  interference  is  likelj^  to  inteiTupt 
pregnancy. 

III.  Diseases  of  the  TTrinary  Apparatus. 

1.  Kidneys. 
(a)  Kidney  of  Pregnancy. — Pathology. — Angemia,  with  fatty  infil- 
tration of  the  epithelial  cells,  and  without  any  acute  or  chronic 
inflammation. 


PATHOLOGY  OF  PREGNANCY.  93 

Cause. — Obscure.  Has  been  attributed  to  pressure  on  the  blood 
vessels  ;  to  the  compression  of  the  gravid  uterus  ;  serous  condition  of 
the  blood  in  pregnancy  ;  influence  of  the  weather,  and  to  spasmodic 
contraction  of  the  renal  arteries.  It  is  most  probably  due  to  a 
diminution  of  the  blood  supply. 

Symptoms. — xllbuminuria.  Hj^aline  and  granular  casts,  with 
epithelium  filled  with  fat,  may  be  found. 

Frequency  and  Course. — About  six  per  cent,  of  all  pregnant 
women  have  albumen  in  the  urine.  Occurs  most  frequently  in  primi- 
parae  ;  nins  a  subacute  course,  manifesting  itself  most  plainly  in  the 
latter  months  of  gestation,  and  can  influence  the  general  health, 
course  of  pregnancy,  and  occurrence  of  eclampsia,  the  same  as 
inflammatory  renal  diseases.  Upon  the  foetus,  also,  it  exerts  practi- 
cally the  same  influence  in  the  production  of  placental  apoplexies. 
The  dangers  are  greatest  when  the  condition  develops  suddenly.  It 
disappears  with  the  cessation  of  gestation. 

Treatment. — Practically  same  as  for  true  nephritis. 

(h)  Acute  and  Chronic  Nephritis. — These  may  occur  at  any  time 
during,  pregnancy,  with  their  usual  sjTnptoms.  The  extra  amount 
of  work  thrown  upon  the  kidneys  at  this  time  makes  the  prognosis 
more  grave,  and  demands  the  most  energetic  treatment.  Premature 
expulsion  of  the  ovum  and  outbursts  of  eclampsia  are  frequent.  The 
chronic  variety  is  more  frequently  a  complication,  and  may  be  acquired 
before  or  during  pregnancy. 

Differential  Diagnosis. — If  the  kidney  disease  existed  before 
pregnancy,  marked  symptoms  will  develop  in  the  earlier  months. 
If  these  develop  in  the  later  months,  the  disease  has  had  its  origin 
during  pregnancy. 

It  is  often  difiicult  to  distinguish  between  the  following  : — 

Chronic  Nephritis.  Kidney  of  Pregnancy. 

Historj'-  may  point  to  its  exist-  Kidneys  normal  at  this  time, 

ence  before  pregnancy. 

Urine  likely  to  be  increased.  Urine  likely  to  be  decreased. 

Presence  of  albuminuric  reti-  Absence  of  same. 

nitis. 

Symptoms    apt    to    be    pro-  Same  in  latter  months, 

nounced  in  earlier  months. 


94  OBSTETRICAL  LECTURES. 

Chronic  Nephritis.  Kidney  of  Pregnancy. 

Autopsy  gives  evidences  of  in-  Anemia  and  fatty  degencra- 

flammatoiy  changes.  tion.     No  inflammatory  changes. 

Persists  after  deliverJ^  Disappears  after  delivery. 

Treatment. — It  is  always  of  paramount  importance  to  know  in  any 
case  of  pregnancy  what  the  condition  of  the  kidneys  may  be,  hence 
in  all  cases  the  urine  should  be  repeatedly  examined,  at  least  every 
ten  days  during  the  latter  weeks.  If  the  quantity  of  albumen  is 
small,  if  there  are  no  casts,  no  history  of  a  previous  nephritis,  and 
no  symptoms  of  general  systemic  disturbance,  dietetic  and  hygienic 
management  may  be  sufficient  so  long  as  the  case  is  kept  under  care- 
ful observation.  When  considerable  quantities  of  urine,  casts  and 
oedema  are  found,  the  patient  should  be  put  to  bed  for  the  greater 
part  of  the  day,  and  milk  diet  and  Basham's  mixture  given. 
Finally,  induction  of  abortion  or  premature  labor  may  be  necessary. 
This  should  not  be  delayed  too  long.  Serious  eye  symptoms  always 
indicate  it.     Eclampsia  can  occur  after  the  expulsion  of  the  foetus. 

(c)  Renal  Tumors. — ^Rare.  Are  to  be  diagnosticated  and  treated 
according  to  the  individual  features  of  the  case. 

{d)  Dislocation  of  the  Kidney. — The  right  is  almost  always  the 
one  afiected.  Not  infi-equently  associated  with  displacements  of  the 
gravid  womb.  Abortion  may  result  if  it  happens  to  become  twisted 
upon  its  pedicle,  and  from  pressure  the  kidney  of  pregnancy  may 
develop. 

(e)  Diseases  of  the  Pelvis  of  the  Kidney. — (1)  Pyelitis.  Premature 
expulsion  of  foetus  apt  to  occur.  It  is  met  with  much  more  fre- 
quently after  labor. 

(2)  Hydronephrosis.  A  displaced  and  adherent  gravid  uterus  may 
occlude  the  ureters  with  this  result.  Requires  reposition  of  the 
uterus. 

(3)  Stone.  Apt  to  induce  abortion.  Renal  colic  is  to  be  treated 
in  the  usual  manner. 

2.  Diseases  of  the  Bladder. 

{a)  Irritability. — Is  ftmctional,  and  occurs  in  hyperaesthetic  indi- 
viduals from  pressure  of  the  gravid  womb. 

Treatment. — Reposition  of  uterus  if  displaced.  When  neurotic, 
nerve  sedatives  are  indicated. 


PATHOLOGY  OF  PREGNANCY.  95 

(/>)  Incontinence  of  Retention. — Is  the  most  common  symptom  of 
a  backward  displacement. 

(c)  Vesical  Hemorrhoids. — Due  to  increased  blood  supply  and 
pressure  of  womb.  Haematuria  may  be  a  symptom.  If  extreme, 
astringents  may  be  injected. 

{d)  Cystitis. — More  frequent  after  labor ;  complicating  pregnancy, 
it  may  be  due  to  gonorrhoea. 

(e)  Vesical  Calculi.  — Important  that  it  be  discovered  before  labor, 
and  removed  through  the  urethra  or  by  vaginal  lithotomy. 

(/)   Cystocele. — Complicates  labor. 

{g)  Injuries.,  Tumors^  EMropliy. — Are  very  rare,  and  should  be 
treated  as  their  individual  peculiarities  may  indicate. 

3.  Anomalies  of  the  Urine, 

{a)  Polyuria. — An  exaggeration  of  the  physiological  alteration. 

Q))  The  urine  may  be  diminished  in  quantity  and  more  concen- 
trated, as  the  result  of  errors  in  diet  and  inactivity  of  skin  and 
bowels. 

(c)  Idpuria. — Explained  by  the  unusual  quantity  of  fat  in  the 
blood  of  some  pregnant  women.  An  oiled  catheter  may  be  the 
source. 

{d)  Cliyluria. — Is  of  no  pathological  import. 

(e)  Peptonuria. — Occurs  very  rarely  in  pregnancy.  Said  to  be 
diagnostic  of  foetal  death. 

(/)  Hcematuria. — Produced  by  vesical  hemorrhoids. 

(g)  Glycosuria. — Ranks  next  in  importance  to  albuminuria.  May 
be  found  in  fifty  per  cent,  of  cases.  Is  probably  hepatogenic. 
Diabetes  mellitus  occurs  more  frequently  in  pregnant  than  in  non- 
pregnant women,  and  when  it  exists  before  pregnancy,  the  latter 
condition  increases  its  severity.  In  seven  out  of  nineteen  cases  the 
disease  determined  foetal  death,  and  in  four  out  of  fifteen  cases  the 
mother  died  shortly  after  labor. 

IV.  Diseases  of  the  Nervous  System. 

1.  Brain. 

(a)  Inflammatory  Diseases. — Are  accidental   complications   and 

rare  ;  exert  no  special  influence  upon  pregnancy,  nor  do  they  specially 

modify  the  course  of  gestation,  except  cerebro-spinal  meningitis, 


96  OBSTETRICAL  LECTURES. 

wliicli  is  infectious,  and  therefore  lias  the  same  influence  upon  and 
is  influenced  in  the  same  way  by  pregnancy  as  the  other  infectious 
fevers. 

(5)  Anemia  and  Congestion. — (See  Eclampsia).  Apoplexy  result- 
ing from  congestion  has  no  influence  upon  the  course  of  pregnancy 

or  labor. 

2.  Spinal  Cord. 

Inflammatory  Diseases. — Also  accidental  and  without  influence 
upon  pregnancy  and  labor. 

3.  Peripheral  Nerves. 
Obstinate  neuralgias,  which  are  little  benefited  by  treatment,  and 
disappear  after  labor. 

4.  Neuroses. 

(a)  Chorea. — Milder  grades  are  not  uncommon.  Sixty  per  cent, 
of  cases  are  in  primiparse.  Heredity,  chlorosis  and  rheumatism  are 
predisposing  causes.  In  the  graver  variety,  premature  expulsion  of 
the  ovum  is  apt  to  occur,  followed  by  death  of  the  mother  in  about 
thirty-three  per  cent,  of  cases. 

Treatment. — Fowler's  solution,  iron,  and  nutritious  diet  for  the 
milder  cases.  The  graver  cases  may  require  an  anaesthetic,  and  finally 
induction  of  premature  labor,  which  is  usually  followed  by  sponta- 
neous recovery. 

(h)  Epilepsy. — Comparatively  rare.  Usually  does  not  influence 
unfavorably  the  course  of  gestation.  It  is  most  hkely  to  be  confused 
with  Eclampsia  (see  Eclampsia).  The  infant  frequently  dies  after 
birth,  presenting  the  symptoms  of  the  maternal  disease. 

(c)  Hysteria. — Occurs  frequently  in  its  minor  grades,  and,  as  a 
rule,  does  not  exert  an  unfavorable  influence. 

5.  Organs  of  Special  Sense. 

(a)  Eyes. — Failing  vision  should  always  indicate  an  examination 
for  advanced  kidney  disease.  Occasionally  there  occurs  complete 
temporary  bhndness,  associated  only  with  anaemia  of  the  eye-ground, 
due  to  reflex  contraction  of  the  retinal  artery. 

(b)  Hearing. — Disturbances  of  this  sense  are  rare,  usually  tem- 
porary, but  may  be  permanent,  and  up  to  the  present  time  are  in- 
explicable. 


pathology  of  pregnancy.  97 

6.  Psychical  Alterations. 

Melancholia^  raarua^  dementia. 

Frequenqj. — Of  all  cases  of  insanit}^  in  women,  about  eight  per 
cent,  have  their  origin  in  child-bearing.  About  one  in  four  hundred 
confined  become  insane. 

Causes. — {a)  Fredisposing. — Strain  of  gestation  in  those  predis- 
posed by  hereditary  influence  ,  temporaiy  causes  of  mental  disturb- 
ance ;  great  reduction  in  physical  strength . 

(&)  Exciting. — Exaggerated  anaemia,  asfi'om  prolonged  lactation  ; 
septicaemia ;  albuminuria ;  profound  emotions,  as  exaggerated  fear 
of  impending  danger ;  dystocia,  as  hemorrhage  after  labor  ;  great 
exhaustion,  etc.  Chorea  results  rather  from  the  same  predisposing 
causes,  and  should  not  be  considered  an  exciting  cause. 

Symptoms. — May  be  maniacal,  melancholic  or  demented,  i.  e., 
exaggerated  stupidity,  fatuity  and  mental  confusion. 

Time  of  Occurrence. — Most  frequently  during  puerperium,  next  in 
lactation,  and  least  during  pregnancy.  Mania  is  the  most  frequent 
form,  melancholia  next,  dementia  last. 

Diagnosis. — Easy.  Important  to  distinguish  puerperal  insanity 
from  ( 1 )  the  temporary  delirium  of  labor,  (2)  delirium  tremens,  (3) 
the  delirium  of  fever,  especially  septicaemia,  and  (4)  preexisting 
insanity. 

Temporary  Delirium,  of  Lahor. — Exceedingly^  common.  Is  usually 
momentary,  and  varies  in  degree  from  hilarity  to  exaggerated 
mania. 

Deliriwm  Tremens. — Labor,  like  an  accident  or  surgical  operation, 
can  precipitate  an  attack  in  hard  drinkers. 

Delirium  of  Fever. — Most  commonly  due  to  septic  infection.  Often- 
times it  is  necessary  to  wait  until  the  fever  subsides  to  determine 
whether  it  be  the  cause  of  the  mental  symptoms. 

Freexisting  Insanity. — Determined  by  the  previous  histoiy. 

Frognosds. — About  two-thirds  recover  their  reason  ;  of  the  other 
third,  from  two  to  ten  per  cent,  die  of  septic  infection  or  exhaustion ; 
the  rest  remain  permanently  insane. 

Treatment. — Rest  cure,   combined  with   administration  of  iron, 
arsenic  and  nutritious  diet,  together  with  careful  supervision  to  pre- 
vent any  injury  to  themselves  or  attendants. 
7 


98  OBSTETRICAL  LECTURES. 

V.  Diseases  of  the  Circulatory  Apparatus. 

1.  Endocardium. 

Valvular  disease  of  the  heart  usually  has  its  origin  prior  to  preg- 
nancy.    It  may  originate  from  septic  infection . 

Prognosis. — Abortion  is  induced  in  about  twenty-five  percent,  of 
cases  as  the  result  of  placental  apoplexies,  or  stimulation  of  the 
uterus  to  contraction  by  the  accumulation  of  CO 2-  Pregnancy  also 
increases  the  danger  of  the  heart  lesion.  In  fifty-eight  serious  cases 
twenty-three  died  after  premature  delivery  of  the  child.  In  milder 
cases  the  prognosis  is  not  so  grave,  yet  the  danger  is  increased. 
Complications  to  be  dreaded  during  gestation  are  :  {a)  a  fresh  out- 
break of  endocarditis,  fatty  degeneration  of  the  papillary  muscles, 
and  especially  congestion  of  the  lungs.  If  the  disease  be  of  long 
standing  and  advanced  degree,  about  half  the  cases  will  die.  If 
recent  and  limited  the  symptoms  may  only  be  aggravated. 

Treatment. — Same  as  under  other  circumstances.  If  maternal 
life  is  threatened  induce  abortion  or  premature  labor,  guarding 
against  a  fatal  result  after  the  expulsion  of  the  contents  of  the  uterus 
by  venesection  should  other  organs  become  engorged,  and  by  the 
application  of  pad  and  binder  to  prevent  the  ill  effects  of  sudden 
diminution  of  intra-abdominal  pressure. 

2.  Heart  Muscle. 

{a)  Suppurative  myocarditis,  only  seen  in  connection  with  septic 
infection  ;  (b)  brown  atrophy  ;  (c)  fatty  degeneration  which  may 
occur  acutely  inconsequence  of  septic  infection,  or  the  accumulation 
of  poisons  in  the  blood  when  the  kidneys  are  inactive. 

3.  GrRAVEs'  Disease  and  Goitre 
Are  unfavorably  influenced  by  pregnancy. 

4.  Blood  Vessels. 

The  only  disease  of  clinical  interest  is  varicose  veins,  in  rectiun, 
anus,  pelvis,  bladder,  external  genitalia  and  lower  extremities. 

Causes. — Changes  in  the  investing  muscular  sheath  of  the  veins, 
increased  quantity  of  blood,  and  mechanical  disturbances  by  the 
growing  uterus. 


PATHOLOGY  OF  PREGNANCY.  99 

CompUcatiouH. — llujjture  with  possibly  fatal  lieuKjiihage,  or 
extensive  extravasation  of  blood  under  the  skin.  Thromboses  and 
phlebitis  with  suppuration  and  septic  infection  may  occur.  As  the 
result  of  itching  and  scratching,  eczema  or  even  erysipelas  may 
develop. 

Treatment.  —Elastic  bandage  or  stocking  when'in  the  legs.  Small 
doses  of  heart  tonics  may  be  given  and  constipation  avoided. 
Absolute  rest  in  cases  of  thromboses,  to  prevent  embolism.  Lead 
water  and  laudanum  when  there  is  any  inflammation.  Abscesses 
should  be  opened.  A  mechanical  protection  should  be  applied  to 
aiFected  part  to  prevent  the  development  of  eczema  or  erysipelas, 
and.  itching  may  be  relieved  by  weak  solutions  of  carbolic  acid  or 
cocaine. 

5.  Blood. 

Pregnancy  very  often  has  a  direct  influence  in  producing  those 
blood  diseases  which  are  characterized  by  a  marked  alteration  in  its 
constituent  parts.  Pernicious  anaemia  and  leucocythsemia  can  have 
their  origin  in  gestation,  and  should  they  already  exist  their  prog- 
nosis is  rendered  more  serious.  The  anaemia  of  pregnancy  may  be  so 
exaggerated  as  to  simulate  these ,  yet  arsenic,  iron  and  nutritious  diet 
after  delivery  will  usually  efi"ect  a  cure. 


VI.  Diseases  of  the  Respiratory  Apparatus. 

1.  Nose. 

The  sense  of  smell  is  more  acute,  and  peculiarities  in  this  sense 
are  developed,  as  abhorrence  for  certain  odors,  which  may  excite 
nausea  and  vomiting  in  neurotic  individuals. 

More  important  is  the  disposition  to  epistaxis,  which  may  be  so 
severe  as  to  threaten  life.  Mqre  frequently,  however,  this  complica- 
tion occurs  during  labor.  It  can  only  be  relieved  by  the  rapid  termi- 
nation of  labor. 

2.  Larynx. 
If  a  tumor,  tubercular  or  syphilitic  disease  be  present,  there  is  a 
constant  danger  of  oedema  of  the  glottis  which  wnll  require  trache- 
otomy. 


100  obstetrical  lectures. 

3.  Bronchi  and  Lungs. 

(a)  Bronchial  Catarrh  ordinarity  is  not  liannfal,  but  constant 
coughing  can  cause  abortion,  and  the  hydrgemic  condition  of  the 
blood  predisposes  to  pulmonary  oedema. 

(b)  Pneumonia. — Symptoms  are  much  aggravated,  mortality 
increased,  and  in  the  vast  majority  of  cases  the  foetus  is  expelled 
prematurely.     (See  Pathology  of  Puerperium. ) 

(c)  Emphysema.. — Quite  common.  Symptoms  aggravated  and 
abortion  apt  to  occur.  Inhalations  of  oxygen  may  be  given  to  coun- 
teract the  accumulation  of  CO 2. 

{d)  Phthisis. — The  influence  of  pregnancy  upon  this  disease  is 
most  unfavorable,  and  in  those  predisposed  gestation  may  be  the 
determining  factor  which  brings  on  an  attack. 

Treatment. — Cod-liver  oil,  iron  and  nutritious  diet.  After  labor 
forbid  nursing  the  child,  as  lactation  is  a  drain  on  the  mother's 
strength  and  the  infant  may  be  infected. 

»(e)  Miliary  Tuherculosis  is  rapidly  fatal  and  may  be  mistaken  for 
septic  infection. 

(/)  Pulmonary  Embolism  is  a  possible  accident. 

{(/)  Pleuri'iy. — Exerts  no  deleterious  influence  upon,  nor  is  it 
afl"ected  by  pregnancy. 

VII.  Infectious  Fevers 

Are  always  more  serious  when  complicating  pregnancy,  their  symp- 
toms being  more  severe  and  mortality  greater.  Even  measles  at 
this  time  may  become  a  deadly  disorder. 

Upon  pregnancy  their  influence  is,  as  a  rule,  unfavorable.  Sixty- 
five  per  cent,  of  typhoid  cases  are  complicated  by  abortion. 

Syphilis  rather  exerts  its  influence  upon  the  foetus.  If  the 
mother  is  diseased  before  impregnation  the  foetus  and  appendages 
exhibit  characteristic  pathological  alterations.  If  the  mother  acquires 
the  disease  from  the  foetus  she  may  exhibit  all  the  secondary  signs 
without  the  appearance  of  a  primary  lesion.  If  she  be  infected 
during  gestation,  as  a  i-ule,  the  mother  is  affected,  the  foetus  escap- 
ing, although  the  latter  is  not  so  absolutelj^  exempt  from  infection 
as  at  one  time  claimed.  Should  infection  occur  at  the  time  of 
impregnation  the    primarj^    sore   may    become  almost    malignant, 


PATHOLOGY  OF  PREGNANCY.  101 

ulcerate  into  the  vagina,  resist  treatment  and  complicate  the  puer- 
peral state. 

Treatment. — All  the  infectious  diseases  are  to  be  managed  with 
little  reference  to  pregnancy.  If  abortion  is  threatened  it  should 
not  be  combated,  as  it  is  an  effort  on  the  part  of  nature  to  improve 
the  maternal  condition. 

VIII.  Skin  Diseases. 

The  following  are  said  to  have  their  origin  in  pregnancy  : — 

L  Impetigo  Herpetiformis. 

The  favorite  seat  of  the  eruption  is  in  the  groin,  around  the 
umbilicus,  on  the  breasts,  in  the  axilla.  Th-e  small  pustules  become 
cmsts,  around  which  new  pustules  develop  until  the  entire  surface 
of  the  skin  in  the  course  of  three  or  four  months  becomes  covered. 
Rigors,  high  intermittent  fever,  great  prostration,  delirium  and 
vomiting  accompany  the  eruption. 

The  disease  ajDpears,  as  a  rule,  during  the  second  half  of  gesta- 
tion. Modern  observation  has  shown  that  it  is  not  absolutely 
confined  to  pregnancy.  Of  twelve  cases  ten  terminated  fatally,  but 
thej^  exercised  no  influence  upon  the  course  of  gestation. 

2.  Herpes  G-estationis 

Is  characterized  by  a  pemphigoid  efflorescence,  exhibiting  erythema, 
papules,  vesicles  and  bullae.  It  appears  early  in  pregnancy,  con- 
tinues during  gestation,  and  disappears  during  the  puerperal  state. 
Neurotic  symptoms  are  associated  with  it,  showing  its  probable 
nervous  origin. 

3.   Pruritus. 

Its  usual  seat  is  the  external  genitalia.  It  may  be  general. 
Causes. — Neurosis  ;  irritating  discharges  ;  parasites.  Rarely  in  the 
general  variety  it  may  be  necessaiy  to  induce  premature  labor. 

IX.  Injuries  and  Accidents. 
Severe  injuries   usually  result   in   abortion.     The   most   serious 
accidents  are  those  which  cause  rupture  of  some  of  the  larffe  blood- 
vessels of  the  external  genitalia  or  lower  extremities.     One  of  the 


102  OBSTETRICAL  LECTURES. 

rarest  accidents  is  spontaneous  rupture  of  the  uterus.  It  may  occur 
in  consequence  of  a  previous  Caesarean  section  ;  chronic  inflammation 
of  the  uterine  walls,  reducing  them  to  little  more  than  connective 
tissue ;  traumatism. 

X.  Surg^ical  Operations. 

When  hfe  or  health  are  seriously  threatened  by  delay  until  recov- 
ery from  the  puerperal  state,  surgical  operations  upon  pregnant 
women  are  justifiable,  and  permission  may  be  given  for  their  per- 
formance without  very  great  fear  of  inducing  thereby  an  abortion. 

XI.    Abortion,  Miscarriage  and  Premature  Labor. 

Abortion. — Expulsion  of  ovum  before  the  fourth  month. 

Miscarriage. — Expulsion  from  the  fourth  to  the  sixth  month. 

Premature  Labor. — Delivery  of  a  foetus  that  has  become  viable. 

Frequency. — Correct  estimate  dif&cult.  One  to  four  or  five  preg- 
nancies. 

Causes. — (1)  Death  of  the  foetus  ;  (2)  abnormalities  and  diseases 
of  the  membranes  including  the  deciduge  ;  (3)  pathological  condi- 
tions of  the  placenta  and  apoplexies  of  the  ovum  ;  (4)  traumatism ; 
(5)  certain  diseases  of  the  mother  directly  affecting  the  product  of 
conception  (see  Diseases  of  the  Membranes  and  Foetus) ;  (6)  condi- 
tions of  the  mother  causing  contraction  of  the  uterine  muscle  and 
premature  expulsion  of  the  normal  ovum. 

The  last  cause  includes  the  following  : — 

{a)  Irritable  Uterus. — The  expulsion,  in  such  cases,  results  from 
a  trivial  cause,  as,  a  long  walk,  purgatives,  jolting,  congestion  of  the 
pelvic  organs,  chronic  constipation,  reflex  irritation  as  from  suckling, 
extraction  of  a  tooth,  pruritus,  ovarian  disease.  At  the  menstrual 
epoch  these  causes  are  most  liable  to  produce  abortion. 

(Jj)  Spasmodic  muscular  action  in  the  mother. 

1.  Chorea. — Less  than  half  the  cases  go  to  term.  The  prema- 
ture expulsion  of  the  ovum  explained  by  physical  exhaustion,  blood 
stasis  and  excess  of  CO 2  in  the  uterine  muscle  stimulating  to  con- 
traction or  by  choreic  movements  of  the  uterus .  2.  Eclampsia.  More 
than  one-half  the  cases  abort  as  the  result  of  asphyxia  of  the  uterus, 
accumulation  of  urea,  carbonate   of  ammonium   or   ptomaines,  or 


PATHOLOGY  OF  PREGNANCY.  103 

due  to  the  convulsive  action  being  shared  by  the  uterus.  3.  Uncon- 
trollable vomiting  and  cougJdng.  Of  51  cases  20  were  dehvered 
before  term.  4.  Epileptic^  hysterical^  cholmmic  and  tetanoid  con- 
vidsions. 

(c)  Conditions  of  the  maternal  blood  ivhich  stimidate  the  uteriiji  to 
expidsive  efforts. 

1.  Poisons  of  all  the  infectious  ferers.  It  is  yet  undecided  whether 
the  abortion  is  due  to  irritative  action  of  microorganisms,  leuco- 
maines,  or  to  a  diminution  of  the  oxygenating  power  of  the  blood. 
When  there  is  an  accumulation  of  CO2,  as  in  pneumonia,  heart  dis- 
ease, emphysema,  etc.,  inhalations  of  oxygen  may  be  given  with 
some  hope  of  success.     2.   Fever. 

(d)  Local  conditions. 

].    Tubal  or   ovarian  diseases.,    tcith  perimetritis  and  adhesions. 
2.   Fibroids.,  polyps.      3.    Uterine  displacements.     4.   Laceration  of 
the  cervix  in  irritable  uteri.     5.    Over-distention  from  hydramnion 
or  midtiple  pregnancy. 

(e)  Placenta  prwvia,  obesity.,  contagious  abortion.  These  are 
rare  causes,  and  the  last  are  really  cases  of  septic  infection. 

Clinical  Phenomena. — 1.  Hemorrhage.  2.  Pain.  3.  Expul- 
sion of  some  portion  of  the  ovum.  All  three  are  rarely  typically 
manifested  in  every  case.  Their  duration  varies  from  almost  in- 
stantaneously to  days  or  weeks.  In  early  abortions  hemorrhage  is 
more  pronounced  than  pain,  and  the  blood  is  extmded  in  coagula. 
The  appearance  of  the  substance  expelled  varies  with  the  period  of 
pregnancy  and  entirety  of  the  product  of  conception.  The  chorional 
coat  may  be  entire,  the  deciduae  alone  may  surround  the  embryo,  or 
it  may  be  surrounded  by  the  amnion.  Most  frequently  the  decidua 
vera  remains  behind,  and  hence  the  danger  of  sepsis. 

Mortality. — In  926  cases  there  were  13  deaths,  a  mortality  of  1.4 
per  cent. 

Diagnosis. — {a)  Threatened  abortion.  Hemorrhage,  and  more 
or  less  pain  in  a  patient  with  signs  of  early  pregnancy. 

(6)  Inevitable  abortion.  Persistent  hemorrhage  ;  dilatation  of 
OS  ;  ovum  presenting  ;  considerable  pain  ;  portions  of  ovum  ex- 
pelled :  effacement  of  the  angle  between  the  upper  and  lower  ute- 
rine segment  (Tarnier).  Exceptionally  one  or  more  of  these  may 
be  present  and  the  case  go  to  term. 


104  OBSTETRICAL  LECTURES. 

(c)  Incomplete  abortion.  Examination  of  fragments  discharged 
by  floating  them  in  water.  Digital  examination  will  usually  find  the 
OS  patulous,  and  detect  shreds  of  deciduae,  the  placenta  or  foetal 
membranes  in  the  uterine  cavity. 

{d )  Complete  abortion.  Uterus  is  firmly  contracted  ;  os  retracted 
and  digital  examination  of  the  uterine  cavity  difficult  or  impossible. 
The  diagnosis  must  depend  upon  the  history  ;  the  examination  of 
the  discharge  ;  the  enlarged  uterus  ;  lochial  discharge,  and  possibly 
the  establishment  of  milk  secretion,  which  is  more  marked  the  later 
the  date  of  pregnancy.  Finally,  the  disappearance  of  the  presump- 
tive signs  of  pregnancy  which  had  previously  existed 

Diagnosis  of  Miscarriage. — Escape  of  liquor  amnii  indicates  rup- 
ture of  the  membranes.  As  the  result  of  the  death  of  the  foetus, 
there  is  a  cessation  of  foetal  movements  and  growth  of  the  uterus,  a 
disappearance  of  the  reflex  and  psychical  disturbances  characteristic 
of  pregnancy,  and  possibly  the  appearance  of  the  milk  secretion. 
The  pain  is  greater  than  in.  abortion  and  is  more  like  labor  pain.  At 
this  stage  of  pregnancy  the  placenta  is  intimately  adherent  to  the 
uterine  wall,  and  often  fails  to  become  detached.  For  this  reason 
the  hemorrhage  is  apt  to  be  serious  and  the  danger  of  sepsis 
great. 

Prognosis  of  Abortion  and  Miscarriage.  — The  ovum  is  inevitably 
destroyed.  The  dangers  to  the  woman  are  hemorrhage,  particularly 
its  secondary  efi"ects,  and  sepsis.  Retained  fragments  may  develop 
into  polypi. 

Treatment. — (a)  Preventive.  Includes  the  treatment  of  the 
causes  that  may  exist  in  any  given  case.  Enjoin  rest  at  menstrual 
epoch,  and  restrain  sexual  intercourse  where  there  is  an  irritable 
uterus.  Replace  a  displaced  uterus  ;  repair  a  lacerated  cervix  ;  treat 
any  inflammatory  condition  about  the  uterus.  If  it  be  due  to  any 
of  the  general  diseases,  do  not  attempt  to  interfere  and  prevent  the 
occurrence  of  tbe  abortion. 

Q))  Threatened  Abortion.  Absolute  rest  in  bed.  Drugs  to 
diminish  nervous  sensibility  and  muscular  action,  as  opium,  potas- 
sium bromide,  chloral.  Opium  should  be  given  in  full  doses  by  the 
mouth,  hypodermatically,  or  by  the  rectum.  The  fluid  extract  of 
viburnum  prunifblium  in  drachm  doses  is  very  efficient.  It  may  be 
combined  with  opium,  administering  the  latter  by  suppository. 


PATHOLOGY  OF  PREGNANCY.  105 

(c)  Inevitable  Abortion.  If  the  hemorrhage  is  profuse  before 
dilatation  of  the  os  occurs,  control  the  bleeding  by  vaginal  tampons 
of  antiseptic  wool  or  baked  cotton.  Remove  in  eight  hours  and  re- 
apply if  required.  Often  when  the  first  one  is  removed,  the  ovum 
or  foetus  may  be  found  extruded,  when  the  urgent  symptoms  may 
subside.  Intrauterine  tampons  of  little  balls  of  iodoform  cotton  or 
strips  of  iodoform  gauze  maybe  used  if  required.  Deciduous  mem- 
brane in  the  earlier  months,  the  placenta  in  the  later,  are  apt  to 
remain  behind.  The  best  method  to  employ  for  their  removal  is  a 
disputed  question.  The  expectant  plan  combines  the  use  of  ergot, 
tampon,  and  great  care  to  avoid  rupturing  the  membranes.  If  the 
abortion  be  incomplete,  rest  in  bed,  small  doses  of  ergot,  vaginal,  and, 
if  possible,  intrauterine,  antiseptic  douches.  At  the  first  indication 
of  sepsis  the  uterine  cavity  should  be  cleared  out. 

The  active  treatment,  which  is  the  better  jjlan,  involves  the  use 
of  the  tampon  to  control  bleeding,  and  as  soon  as  the  os  is  sufii- 
ciently  dilated,  the  removal  of  the  uterine  contents  by  one  of  the 
following  plans  :  The  finger ;  the  curette  in  experienced  hands ; 
the  method  of  expression  (Hoening) ;  the  ecouvillon  (Doleris) ;  after 
which  an  intrauterine  douche  of  a  two  per  cent,  solution  of  creolin 
should  be  given.  If  needed,  Hegar's  dilators  may  be  used  to 
stretch  a  retracted  os. 

After- Treatment. — Very  little  required  after  active  treatment, 
beyond  confinement  to  bed  until  involution  is  complete.  When  the 
expectant  plan  has  been  followed,  antiseptic  douches  are  to  be  used, 
and  the  earliest  sign  of  sepsis  looked  for. 

XII.  Extrauterine  Pregnancy. 

Frequency. — The  exact  proportion  to  intrauterine  gestations  is 
difficult  to  determine.  In  the  larger  cities  a  large  number  occur 
annually.     Many  cases  are  never  diagnosticated. 

Classification  based  upon  the  SituMtion  of  the  Developing  Ovum. 
J.  Tubal. 

{a)  Tubo-uterine  or  interstitial. 
(6)  Tubal  proper, 
(c)   Tubo-ovarian. 

2.  Ovarian. 

3.  Abdominal. 


106  OBSTETRICAL  LECTURES. 

Cause. — Obscure.  Any  disease  of  the  mucous  membrane  of  tbe 
tube  depriving  it  of  cilia,  forming  mucous  polyps  or  otherwise  ob- 
structing its  calibre  predisposes  to  its  occurrence. 

Clinical  Hktory. — In  each  of  the  situations  noted  above,  the 
course  of  gestation  is  somewhat  different,  and  presents  a  different 
clinical  picture  on  account  of  the  difference  in  the  surrounding  ana- 
tomical structures  which  are  involved. 

Changes  in  Uterus  and  Vagina. — In  all  forms  these  changes  are 
rather  constant.  Most  of  the  alterations  characteristic  of  intrauter- 
ine pregnancy  are  found,  i.  e. ,  hypertrophy  of  the  vaginal  mucous 
membrane,  with  increased  blood  supply  (purple  tinge)  and  increased 
secretion  ;  cervix  softened  and  os  patulous  ;  uteras  enlarged,  and, 
in  the  vast  majority  of  cases,  deciduous  membrane  developed,  which 
undergoes  the  same  change  as  in  intrauterine  gestation  preparatory 
to  its  separation  and  extrusion,  which  occurs  in  extrauterine  gesta- 
tion between  the  eighth  and  twelfth  week. 

The  other  changes  in  the  maternal  organism  vary  with  the  situa- 
tion of  the  developing  ovule. 

Clinical  History  of  Tubal  Pregnancies. — The  most  frequent  situa- 
tion of  an  extrauterine  gestation  is  about  the  median  portion  or 
outer  third  of  the  tube.  In  this  position  it  may  grow  upward  into 
the  abdominal  cavity  distending  the  tube  walls  to  the  point  of  rup- 
ture, or  it  may  grow  downward  between  the  layers  of  the  broad 
ligament.  The  tubal  walls  grow  thicker  from  the  development  of 
their  muscle  fibres,  except  at  spots,  especially  on  upper  and  posterior 
surfaces,  where  rupture  may  occur,  the  individual,  perhaps,  expe- 
riencing severe  cramp-like  pain  followed  by  symptoms  of  profound 
shock  and  death  in  a  few  hours.  Exceptionally,  the  gestation 
may  proceed  to  fall  term,  which  is  more  common  when  the  ovule 
has  grown  downward.  When  rupture  occurs  it  usuallj^  takes 
place  between  the  eighth  and  twelfth  week.  If  upon  the  upper 
or  posterior  aspect  of  the  sac  the  contents  are  extruded  into 
the  peritoneal  cavity  with  an  intraperitoneal  hemorrhage.  If 
rupture  occurs  on  the  lower  aspect,  the  contents  and  hemorrhage 
find  their  way  between  the  layers  of  the  broad  ligament  and  pelvic 
fascia,  giving  rise  to  an  extra-peritoneal  hagmatocele.  The  first 
variety  is  usually  fatal ;  the  last  is  not  always  directly  dangerous  to 
life. 


PATIIOLOUY   OF   PREGNANCY.  107 

Clinical  History  of  Interstitial  Pregnancy. — The  ovule  develops 
in  the  uterine  wall,  the  inner  side  of  the  sac  often  projecting  into  the 
uterine  cavity,  and  having  on  the  outer  side  the  round  ligament  and 
the  greater  part  of  the  tube.  The  usual  termination  is  mpture  into 
the  peritoneal  cavitj^  Rupture  into  the  uterine  cavity  and  expul- 
sion of  the  ovum  through  the  cervix  is  jxjssible. 

Clinical  History  of  Tuho-ovanan  Pregnancy. — The  ovum  devel- 
ops between  fimbriae  of  tube  and  ovary.  The  sac  in-xy  mpture  with 
the  usual  consequences  of  such  accident.  It  is  possible,  however, 
to  see  a  development  of  the  ovule  to  maturit}'. 

Clinical  History  of  Ovarian  Pregnancy. — The  ovule,  impregnated 
while  it  is  still  within  the  Grraafian  follicle,  reaches  some  degree  of 
growth  and  development  in  this  situation.  Is  exceedingly  rare.  At 
least  one  undoubted  case  on  record. 

Clinical  History  of  Abdominal  Pregnancy. — x\lso  rare.  Two 
authenticated  cases.  Is  likely  to  go  to  full  period  of  gestation  and 
mature  development  of  foetus. 

Terminations  of  Extrauterine  Pregnancy. 

{a)  Rurpture  of  tJie  Sac  and  Profuse  Hemorrhage. — Occurs  most 
commonly  in  the  tubal  variety,  where  the  growth  is  upward  toward 
abdominal  cavity.  May  occur  when  the  ovule  grows  down  between 
layers  of  broad  ligament  ;  also  in  tubo-uterine,  tubo-ovarian,  ovarian 
and  abdominal.  Up  to  second  month  the  extruded  embryo  may  be 
absorbed. 

(h)  Rupture  of  sac  tcith  extrusion  of  contents,  and  interstitial  hem- 
orrhage  into  sac  tcalls  icithout  escape  of  blood  into  peritonecd  cavity 
or  between  layers  of  broad  ligament.  — This  is  followed  by  atrophy  of 
ovum  and  sac. 

(c)  Death  of  the  Foetus  after  its  Maturity. — Occurs  most  often  in 
abdominal  or  tubo-ovarian,  though  possible  in  pure  tubal.  1.  The 
foetus  may  be  converted  into  a  lithopgedion.  2.  The  soft  parts  may 
macerate,  leaving  the  bones,  which  may  remain  as  an  abdominal 
tumor  or  ulcerate  into  bladder  or  intestines.  3.  The  foetal  body  may 
putrefy  from  contiguity  of  the  intestines  and  their  contained  micro- 
organisms and  access  of  germs,  {d)  In  the  case  of  ovarian  preg- 
nancy, arrest  of  development  of  the  ovum  at  an  earl.y  period  oc- 
curred, and  the  small  cystic  tumor  containing  the  foetal  bones  was 


108  OBSTETRICAL  LECTURES. 

retained,  (e)  lu  tuho-uterine,  the  ovum  and  embryo  may  be  dis- 
cbarged  into  the  uterine  cavity  and  evacuated  by  the  natural  pas- 
sages. (/)  In  one  case  of  so-called  tubal  abortion  there  was  an 
internal  rupture  of  the  ovum,  and  blood  was  poured  through  the 
fimbriated  extremity  of  the  tube  into  the  abdominal  cavity,  {g)  It 
is  asserted  that  a  tubal  pregnancy  may  nipture  in  its  early  stages, 
the  embryo  be  expelled  into  the  abdominal  cavity,  retaining  its  con- 
nection with  the  tube  by  the  cord  and  placenta,  and  the  foetus  con- 
tinue to  full  development.  This  is  called  a  secondary  abdominal 
pregnancy.  Rupture  in  these  cases  has  probably  not  occurred,  and 
the  sac  wall  carefully  examined  would  probably  show  enormous  dila- 
tation of  the  tubal  wall.  (A)  G-rowth  and  development  of  the 
placenta  after  foetal  death  has  been  asserted.     This  does  not  occur. 

Symptoms. — («)  Subjective.  In  the  early  months  may  be  indis- 
tinguishable fi'om  those  of  intra-uterine  gestation.  In  the  tubal 
variety,  which  is  more  common,  there  is  usually  no  indication  of 
any  abnormality  until  nipture  occurs.  In  some  cases  this  may  be 
preceded  by  severe  cramp-like  pain,  accompanied  or  followed  by  the 
discharge  of  deciduous  membrane.  When  advanced  development 
occurs,  as  in  abdominal  and  some  cases  of  tubal,  no  symptoms  may 
arise  until  the  time  for  labor  has  passed,  when  pain  and  other  com- 
plications may  arise. 

(6)  Objective.  1.  Tubal.  Tumor  felt  to  one  side  of  the  uterus, 
which  is  smaller  than  would  be  expected  from  the  duration  of  the 
pregnancy.  The  uterus  is  usually  displaced  forward,  backward,  or 
to  the  side  opposite  the  tumor.  * 

2.  Interstitial.  Diagnosis  difficult  or  impossible .  The  uterus  en- 
larges to  a  greater  degree  than  in  any  other  variety,  and  it  may  be 
impossible  to  determine  whether  or  not  it  is  symmetrically  enlarged. 

3.  Abdominal.  When  the  ovum  occupies  Douglas'  pouch,  the 
foetal  parts  may  be  made  out.  A  sacculated  uterus  may  be  mistaken 
for  this. 

Diagnosis. — In  spite  of  a  most  careful  history  and  physical  exami- 
nation, the  diagnosis  is  occasionally  impossible.  Usually  it  is  not 
made  until  rapture  has  occurred.  At  this  time  a  history  of  early 
pregnancy,  sudden  collapse  and  symptoms  of  internal  hemorrhage, 
with  a  vaginal  examination  showing  effusion  into  peritoneal  cavity, 
makes  the  diagnosis  and  indicates  immediate  laparotomy  to  prevent 


PATHOLOaY  OF  PREGNANCY.  109 

further  hemonliage  and  peritouitis.  Should  tlie  cvamp-like  pain 
cause  a  patient  to  consult  a  physician,  and  should  she  give  a  clear 
history  of  impregnation — all  the  earlier  signs  of  pregnancy,  the  dis- 
charge of  blood  and  membrane,  which  the  micrr)SCOpe  shows  to  be 
decidual,  with  the  detection  of  a  tumor  in  the  neighborhood  of  the 
uteras,  on  whicli  balhjttement  may  perhaps  be  practiced*  and  the 
uterus  not  very  mucli  enlarged — the  diagnosis  is  justified,  and  treat- 
ment also,  even  if  it  involve  a  serious  operation.  Among  the  con- 
ditions in  the  pelvis  that  may  make  the  diagnosis  impossible  are 
abortion,  in  consequence  of,  or  coincident  with,  some  growth  near 
the  uterus  ;  pyosalpinx,  with  an  indistinct  or  untrastworthy  history 
of  pregnancy  ;  intrauterine  pregnancy,  with  rapid  development  of  a 
fibroid  on  one  side  of  the  uterus  ;  development  of  an  impregnated 
ovule  in  one  horn  of  a  two-honied  utenis  or  on  one  side  of  a  double 
uterus. 

Treatment. — Differs  as  it  is  met  with  in  its  early  stages,  or  after 
Tupture  ;  whether  interstitial,  tubal,  ovarian  or  abdominal  ;  whether 
the  foetus  has  reached  advanced  development,  as  in  abdominal ; 
whether  the  conditions  f(jllowing  foetal  death  require  the  treatment. 

If  the  diagnosis  has  been  made  early.,  electricity  or  laparotomy  and 
removal  of  the  foetal  sac.  The  ordinarj^  practitioner  should  first  tiy 
electricity.  Thefaradic  current  seems  to  be  the  most  efficient.  One 
electrode  in  rectum,  the  other  over  Poupart's  ligament,  on  the  side 
occupied  by  the  sac.  The  fall  strength  of  a  single-celled  batteiy 
may  be  passed  through  the  sac,  and  if  the  growing  contents  of  the 
•sac  are  destroyed,  the  whole  ovum  may  ultimately  disappear.  A 
galvanic  current  of  10  milliamp^res  may  be  employed.  Electricity 
fails  in  a  certain  proportion  of  cases,  and  laparotomy  is  the  only 
resource,  which,  in  these  cases,  is  almost  always  a  difficult  opera- 
tion, not  to  be  undertaken  by  an  unskilled  operator. 

After  rvpture  the  indication  is  for  immediate  laparotomy,  evacua- 
tion of  the  blood  from  peritoneal  cavity,  ligature  of  the  sac,  and  its 
entire  removal.  Kupture  followed  by  hemorrhage  is,  however,  not 
invariably  fatal. 

In  interstififd  little  can  be  done  until  mpture  and  hemorrhage 
have  occurred,  when  laparotomy  may  be  performed,  ligating  the 
bleeding  point,  and,  if  possible,  clearing  the  sac  of  its  contents, 
along  with  the  placenta.     Where  this  is  impossible,  supra-vaginal 


110  OBSTETRICAL  LECTURES. 

amputation  of  the  uterus  is  indicated.  It  mi^ht  be  well,  the  diag- 
nosis being  established,  to  try  to  effect  evacuation  of  the  foetal  sac 
into  the  uterine  cavity  after  thorough  dilatation  of  the  cervical 
canal.  A  mistaken  diagnosis,  however,  would  lead  to  a  premature 
termination  of  a  normal  intrauterine  pregnancy. 

Tubal. and  ovarian  are  to  be  treated  as  outlined  above,  when  dis- 
cussing the  treatment  of  early  extrauterine  gestation  and  after  rup- 
ture. 

In  the  ahdominal  variety,  always  delay  until  just  before  the 
natural  duration  of  normal  pregnancy,  when  the  foetus  and  foetal  sac 
should  be  extracted  by  abdominal  section.  Five  such  operations 
have  been  done,  with  five  maternal  recoveries.  In  advanced  cases, 
ill  tvhich  death  of  the  foetiis  has  occurred,  it  is  best  not  to  subject 
the  woman  to  the  danger  of  the  several  possible  terminations,  but  to 
perform  laparotomy  and  remove  the  foetus  and  its  entire  surround- 
ing sac.  If  the  exsection  of  the  sac  is  found  to  be  too  difiicult  or 
dangerous,  it  is  permissible,  some  weeks  after  foetal  death,  to  cut  off 
the  cord  short,  leave  behind  the  atrophied  remains  of  the  placenta, 
stitch  the  sac  wall  to  the  abdominal  wall,  and  thus  drain  the  sac 
externally. 

Labor. 

Physiolog'y. 

Labor  occurs  usually  280  days  after  the  appearance  of  the  last 
menstrual  period. 

Causes  of  Occurrence  at  this  Time. 

{a)  Periodicity. — The  muscular  action  at  the  periods  is  especially- 
marked  at  the  tenth. 

(6)    Over-distention  of  Uterus,  followed  by  Retraction. 

(c)  Maturity  of  Ovum  (fatty  change  of  attachment). 

{d)  Heredity,  or  Body  Habit,  which  is  perhaps  the  most  powerful. 

At  this  time  slight  causes,  as  exercise,  purges,  excitement,  may  begin 

the  process. 

Signs  of  Beginning  Labor. 

(a)  Subsidence  of  Uterus. — This  is  a  premonitory  sign.  Occurs 
about  four  weeks  before  term  in  primiparae,  two  weeks  or  less  in 
multiparae. 


LABOR.  Ill 

Cause. — Over-distention  of  abdominal  muscles.  It  may  occ-ur 
suddenly,  and  be  followed  by  relief  of  pressure  symptoms  above, 
while  those  below  may  be  increased,  as  excessive  vaginal  secretion, 
oedema,  etc.  If  it  does  not  occur,  it  indicates  a  malposition  of  the 
foetus,  or  some  obstruction,  as  contracted  pelvis. 

{h)  Pains. — Are  colicky,  intermittent ;  felt  over  the  sacrum,  or 
beginning  in  front  and  passing  back  to  sacrum. 

(c)  Blood-tinged  Mucus. — Due  to  expulsion  of  the  mucous  plug 
in  cervix  and  torn  ceiTical  vessels. 

{d)  DiIatatio7i  of  Os. — The  most  important. 

Clinical  Signs  of  Labor. 

(a)  Contractions  of  Uterine  Muscle. — At  each  contraction  the 
uterus  drives  the  liquor  amnii  through  the  cervix,  diminishes  the 
area  of  intrauterine  space,  and  produces  an  expansion  of  the  birth 
canal.  The  contraction  lasts  about  a  minute,  recuning  at  intervals 
of  ten  to  fifteen  minutes,  which  decrease  as  labor  advances. 

(6)  Behavior  of  the  Fatient. — For  about  the  first  ten  hours  the 
sacral  pains  are  increasing  in  frequency  and  severity.  During  the 
second  stage  the  voluntary  muscles  are  brought  into  play,  as  shown  by 
her  straining  and  bearing-down  eiForts,  the  pains  increase  in  frequency 
and  strength,  and  there  is  a  desire  to  emi:)ty  bladder  and  rectum. 

(c)  Phenomena  of  Birth  of  Head  and  Shoulders. — The  head 
retracts  after  each  pain,  and  there  is  an  intense  pain  and  outcry  as 
the  head  passes  the  perineum.  Restitution  is  followed  by  birth  of 
anterior  shoulder. 

A  condition  of  contentment  and  happiness  succeeds  the  birth  of 
the  child. 

Phenomena  of  Placental  Separation  and  Expulsion. — Theories 
of  its  separation  : — 

(a)  Placental  area  diminished. 

(6)  Placenta  pushed  off. 

(c)  Separated  by  retro-placental  clot. 

The  first  probably  correct. 

Theories  of  Expulsion  : — 

(a)  Edgewise  (Matthew  Duncan). 

(6)  Like  inverted  umbrella  (Schultze). 

The  last  probably  correct. 


112  .    OBSTETRICAL  LECTURES. 

The  pouch-like  dilated  lower  uterine  segment  often  contains  the 
placenta,  hence  artificial  aid  in  its  complete  expulsion  often  required. 
A  slight  elevation  of  temperature  is  normal  after  labor. 

Manag-ement  of  Labor. 

Summons  to  an  obstetric  case  should  receive  immediate  attention. 

(a)  Arinamentarium. — Ether,  brandy,  vinegar,  a  large  new 
sponge,  pads,  clothing  for  mother  and  child,  should  be  provided 
before  confinement.  The  obstetric  bag  should  contain  :  soap,  nail- 
brash,  tablets  of  bichloride,  iodoform  tape,  or  antiseptic  Chinese 
silk,  pocket-case  with  sutures  and  needles,  ergot,  hypodermic  syringe, 
iodoform  gauze,  absorbent  cotton,  a  ten  per  cent,  solution  of 
cocaine,  forceps. 

(b)  The  Exammation.  —  Abdominal  palpation  and  auscultation 
should  determine  the  position  and  presentation,  touch  should  ascer- 
tain the  state  of  the  perineum,  dilatability  of  vagina,  and  its  secre- 
tions, roominess  of  pelvis,  condition  of  cervix,  effectiveness  of  pains, 
and  should  confirm  diagnosis  of  presentation. 

(c)  Treatment  of  the  First  Stage. — The  bowels  should  be  evac- 
uated by  an  enema,  urine  voided,  patient  allowed  to  remain  out  of 
bed,  examinations  to  be  made  at  intervals  of  an  hour  or  hour  and 
a  half,  and  when  the  os  is  the  size  of  a  silver  dollar  the  patient 
should  be  put  to  bed,  lying  on  that  side  toward  which  the  back  of 
the  foetus  looks. 

(d)  Ancesthema. -^CoGMne  and  belladonna  are  not  effective.  Chlo- 
roform is  not  dangerous.  Ether  is  preferable,  except  in  eclamjDsia. 
By  giving  it  only  in  the  second  stage  its  administration  for  too  long 
a  time  is  avoided,  and  bj^  producing  only  analgesia  an  excessive 
amount  is  not  employed. 

(e)  Rupture  of  the  Memhranes. — In  a  primipara  the  membranes 
should  never  be  ruptured,  and  in  multiparas  only  in  the  second 
stage.  Finger,  match,  hairpin,  etc.,  may  be  used  to  break  them, 
the  operation  being  performed  in  the  absence  of  a  pain,  with  the 
assurance  that  membranes  are  present,  and  not  the  lower  uterine 
segment,  thin  from  pressure  of  the  head. 

(/ )  Treatment  of  the  Second  Stage.  — Examinations  should  now 
be  made  every  five  or  ten  minutes.  A  puller  may  be  employed  to  in- 
crease the  abdominal  force. 


LABOR.  113 

The  Perineum. — Bad  lacerations  of  the  perineum  are  avoidable. 
In  primiparae  the  fourchette  is  torn  in  61  per  cent,  of  cases,  the 
perineum  in  34  per  cent.  ;  in  multipara?,  the  perineum  in  9  per 
cent. 

Causes : — 

{a)  Relative  disproportion  between  the  size  of  the  head  and  out- 
let. 

(6)  Precipitate  expulsion. 

(c)  Faulty  mechanism. 

Preceative  Treatment. — Depends  largely  upon  the  cause.  If  the 
disproportion  be  great,  episeotomy  may  be  required  ;  if  expulsion 
precipitate,  retard  the  head  by  hand  or  forceps;  in  some  faulty 
mechanisms  the  forceps  can  be  used  to  correct  them,  as  by  elevating 
the  handles  when  the  head  is  overflexed,  etc.  A  routine  treatment, 
based  upon  the  most  frequent  cause,  is  to  retard  e^rpuhion  by  resist- 
ing the  head  and  pressing  it  toward  the  pubes,  restraining  voluntary 
eiforts  and  using  them  during  the  absence  of  pains. 

The  Head. — When  the  head  is  born  avoid  traction,  support  it, 
and  if  the  cord  be  coiled  around  the  neck,  loosen  and  slip  it  over  the 
head,  allow  the  shoulders  to  pass  through  it  or  cut  it  between  two 
ligatures. 

The  Shoidders. — Avoid  increasing  any  tear  the  head  may  have 
made. 

Treatment  of  the  Third  Stage. — Indications  are,  (1)  prevent 
hemorrhage,  and  (2)  deliver  the  placenta.  Secure  contraction  and 
retraction  of  the  uterus  by  external  and  internal  stimuli  :  externally, 
by  frictions  through  abdomen,  continued  for  fifteen  minutes  and  fol- 
lowed by  the  application  of  a  pad  and  binder  :  internally,  by  admin- 
istering 5j  of  the  fid.  extract  of  ergot. 

The  binder  should  be  12  in.  by  1\  yds.,  preferably  many-tailed, 
and  the  pad  should  be  placed  over  the  umbilicus. 

The  placenta  is  separated  by  a  diminution  of  the  placental  area, 
and  its  delivery  should  be  accomplished  by  resorting  to  the  Crede 
method  fifteen  minutes  after  the  birth  of  the  child.  Remember 
that  the  movement  of  "  expression  "  should  be  tcith  a  xjain. 

The  Infant. — After  pulsations  in  the  cord  cease,  apply  two  liga- 
tures, for  cleanliness,  and  cut  between  them  across  the  palm  of  the 
hand.     The  ligature  should  be  tied  with  the  surgeon's  knot,  followed 
8 


114  OBSTETRICAL  LECTURES. 

by  an  ordinary  bow-knot,  to  permit  tightening  after  the  child  has  had 
its  warm  bath.  Before  the  cord  is  dressed  it  should  be  stripped. 
The  vernix  caseosa  should  be  removed  by  some  oily  substance,  fol- 
lowed by  soap  and  water.  Salioylated  cotton  should  be  used  to  dress 
the  cord,  and  the  binder  then  applied. 


Puerperium. 

Physiology. 

The  child-bearing  process  is  divided  into  four  periods,  viz. :  Preg- 
nancy, Labor,  Puerperium  and  Lactation.  The  puerperium  is  the 
period  from  birth  to  the  time  when  the  uterus  has  regained  its 
normal  size,  which  is  six  weeks.  Dimensions  of  uterus  at  9th  month, 
2  lbs.,  12  X  9  X  8i^  in.,  400  cu.  in.  Dimensions  of  uterus  6  weeks 
after  labor,  2  oz. ,  1  cu.  in.  These  changes  in  the  uterus,  its  lining 
and  adnexa  result  from  the  process  known  as  Involution. 

Anatomical  Development  of  the  Pregnant  Uterus. — Subsequent 
to  impregnation  the  muscle  cells  take  on  a  new  growth,  and  in  their 
development  hypertrophy  into  muscular  fibres  four  times  as  broad 
and  eleven  times  as  long.  There  is  a  similar  increase  in  blood  ves- 
sels, connective  tissue,  lymphatics  and  nerves. 

Anatomical  Changes  During  Involution. — As  a  result  of  the  de- 
crease in  blood  supply,  which  normally  repairs  tissue  waste,  the 
superabundant  uterine  tissue  undergoes  degeneration,  chiefly  fatty, 
and  is  carried  away  by  the  blood  vessels  and  in  the  discharges,  in 
part  as  peptones.  The  process  is  really  an  atrophy,  which  ceases 
after  the  enlarged  muscle  cells  have  been  reduced  to  their  original 
size.  From  the  anatomical  arrangement  of  its  fibres  the  parturient 
nterus  is  composed  of  two  segments,  the  upper  muscular,  with  its 
fibres  arranged  crosswise,  the  lower  largely  fibrous,  arranged  longi- 
tudinally. In  the  process  of  involution  the  upper  undergoes  the 
greatest  change,  while  the  lower,  including  the  vagina,  is  mainly  a 
retraction  of  overstretched  tissue,  which  never  completely  regains  its 
tone.  The  lining  membrane  of  the  uterus,  or  decidua,  is  composed 
of  an  upper  cellular  and  lower  glandular  layers.  The  upper  is 
partly  removed  when  the  ovum  is  delivered,  and  the  remainder  dis- 
integrates as  the  blood  supply  diminishes,  until  the  epithelial  struc- 


PUERPERIUM.  1 ] 5 

tures  of  the  glandular  layer  are  exposed,  and  from  these  epithelial 
cells  in  the  glandular  layer  the  mucous  membrane  is  renewed. 

Lochia. — {a)  Lochia  Rubra.  Bloody,  last  four  to  five  days.  (6) 
Serosa.  Composed  of  disintegrating  tissue,  pus  cells,  mucus  and 
water,     (c)  Alba.     Composed  of  healthy  pus. 

Quantity. — First  four  days,  1  kilo.,  or  2.2  lbs.  Next  two  days, 
280  grams,  or  ]5  oz.  Until  the  ninth  day,  205  grams,  or  7  oz. 
—31  lbs  in  all. 

Quantity  is  estimated  by  the  number  of  napkins  soiled.  In  the 
first  twenty-four  hours  the  pads  should  be  changed  six  times,  during 
the  next  four  daj^s  three  times  a  day,  raid  after  the  fifth  day  twice  a 
day.  A  personal  examination  by  the  physician  should  always  ascer- 
tain their  odor,  which  is  at  first  bloody,  later  like  that  of  the  genitalia. 
A  putrid  odor  is  the  danger  signal  of  decomposition  and  sepsis. 

Conditions  modifying  the  force  and  frequency  of  pains  which 
secure  involution : — 

(a)  Individuality. 

(b)  Always  greater  in  primiparae. 

(c)  Over-distention  of  the  utenis. 
After-pains. — Uterine  action  is  excited   by  retained  blood  clots. 

They  occur  most  frequently  in  multiparas,  and  may  be  distinguished 
from  periuterine  inflammation  by  being  cramp-like,  intermittent  and 
not  increased  by  pressure,  the  pulse  and  temperature  not  influenced. 
Paregoric  5j  with  ergot  ,^ss,  every  2  or  3  hours,  will  usually  control 
them. 

The  Circulation. — The  pulse,  which  is  accelerated  during  labor  to 
80  or  90,  falls  to  60  or  lower,  as  a  result  of  the  diminished  arterial 
tension  after  labor.  The  heart  is  found  to  be  hypertrophied  and 
dilated,  the  result  of  the  increased  demands  made  on  the  circulation 
during  pregnancy. 

Secretions  and  Excretions. — All  are  more  active  to  diminish  the 
hydraemic  condition  of  the  blood,  get  rid  of  eff"ete  material  and 
prevent  rise  of  temperature. 

(a)  TIrinanj  Function. — The  urine  is  increased  in  amount,  is  more 
watery,  all  the  solids  except  the  chlorides  being  decreased.  Sugar 
is  found  in  50  per  cent,  of  cases.  .  Peptonuria.  The  kidneys  are 
hypertrophied.  There  is  frequently  difficulty  in  emptying  the 
bladder,  which  may  be  due  to  the  following  causes  : — 


116  OBSTETRICAL  LECTURES. 

(1)  DuriDg  pregnancy  the  bladder  can  only  expand  upward,  and 
this  liabit  is  acquired  at  that  time.  After  labor  it  expands  in  all 
directions  and  admits  of  greater  distention  before  the  walls  respond 
and  contract. 

(2)  The  abdominal  walls  are  relaxed,  and  this  factor  in  emptying 
fails. 

(3)  (Edema  and  over-stretching  of  the  soft  parts  from  pressure  of 
the  head  may  diminish  the  calibre  of  the  urethra  and  make  its 
course  tortuous.  The  difficulty  in  such  cases  often  passes  away 
when  the  catheter  is  used  once. 

(Jj)  Skin. — Sweat  is  increased. 

(c)  Lungs. — Capacity  increased.  The  expired  air  contains  more 
water  and  effete  products. 

{d)  Boicel. — Sluggish,  from  pressure. 

(e)  Thirst.  — Increased  by  the  large  amount  of  liquid  lost. 

(/)  Appetite. — Diminished.  Two  pounds  of  muscle  (uterus)  and 
the  subcutaneous  fat  developed  during  pregnancy  are  being  ab- 
sorbed. 

{g)  Weight. — There  is  a  loss  in  weight  (i  to  xS"  of  the  body 
weight). 

(A)  Temperature. — No  rise  of  any  consequence. 

Developjiental  Changes. 

Mammary  Function. — Each  mammary  gland  is  divided  into  15  or 
20  lobes,  and  these  are  farther  subdi^^ded  into  lobules  and  vesicles. 
Each  lobe  has  a  duct,  dilated  before  reaching  but  contracted  when 
entering  the  skin.  Forty-eight  hours  after  labor  the  breasts  enlarge, 
the  veins  engorge  and  become  painful  and  tender.  At  this  time 
the  secretion  changes  from  colostrum  to  milk.  Colostrum  is  the 
secretion  which  appears  after  the  fourth  month  of  pregnancy.  It 
contains  no  casein,  albumen  taking  its  place,  which  is  a  laxative  to 
the  foetus. 

Diagnosis  of  the  Puerperal  State. — Some  of  the  more  important 
signs  are  :  (a)  the  presence  of  milk  in  the  breasts,  (6)  the  enlarged 
uterus,  (c)  lacerations  along  the  birth  canal  and  {d)  the  lochial  dis- 
charge containing  decidual  cells. 


PUERPERIUM.  117 

Management  of  the  Puerperium. 

1.  Avoidance  of  Septic  Infection. — Accomplished  by  securing  (a) 
chemical  cleanliness  of  patient,  doctor  and  nurse,  and  ih)  removal  of 
all  bloody  cloths,  excretions  and  food  ;  (c)  secure  ventilation,  and 
look  for  possible  insanitary  plumbing. 

2.  Visits. — If  the  labor  has  occurred  in  the  moraing,  the  patient 
should  be  visited  in  the  afternoon,  and  daily  for  one  week,  subse- 
quently every  other  day.  At  each  visit  examination  should  be  made 
of  the  temperature,  pulse,  nipples  and  breasts,  and  the  lochia.  The 
uterus  should  be  palpated,  and  the  passage  of  urine  inquired  for. 
The  child's  umbilicus  should  be  examined  for  any  bleeding  and  pas- 
sage of  its  urine  and  faeces  noted.  The  nurse  should  receive  direc- 
tions as  to  diet,  catheter  and  the  recording  of  temperature  three 
times  a  day. 

3.  Secure  Rest  and  Quiet. — The  patient  should  lie  on  her  back 
for  three  days,  and  without  a  pillow  for  the  first  six  hours,  to  avoid 
syncope.  She  can  be  made  more  comfortable  by  moving  her  from 
side  to  side  and  alcohol  rubbings.  She  should  be  kept  in  bed  until 
the  fundus  is  at  or  below  the  symphysis,  usually  in  ten  daj's,  when 
restricted  exercise  should  be  enjoined,  to  prevent  uterine  disorders, 
as  flexions,  etc.  In  the  better  classes,  until  the  fourteenth  day,  and 
restricted  to  room  for  four  weeks.  Involution  is  best  hastened  by 
promoting  the  natural  process  and  a  suitable  diet.  The  prolonged 
use  of  ergot  is  rather  unfavorable,  because  of  its  effect  upon  the 
milk  secretion  and  stomach  of  mother  and  child.  The  degree  of 
quiet  should  be  absolute,  and  the  mother  and  husband  the  only  visit- 
ors admitted  while  the  patient  is  in  bed. 

4.  Secure  Emptying  of  the  Bladder. — Xever  trust  anybody  s 
statement  of  the  passage  of  urine.  After  twelve  hours,  if  needed, 
the  meatus  should  be  cleansed  with  cotton  dipped  in  bichloride  solu- 
tion and  a  soft  and  antiseptically  clean  catheter  i^assed  at  least  three 
times  a  day. 

5.  Diet. — Opinion  differs.  Alight,  easily-digested  diet  gives  least 
disturbance,  and  is  ])referable. 

6.  Bowels. — On  the  third  day  castor  oil.  Compound  licorice  pow- 
der may  be  used,  and  if  the  inflammatory  changes  during  the  milk 
formation  be  great,  an  active  saline  should  be  given. 


118  OBSTETRICAL  LECTURES. 

7.  Breasts. — For  threatened  inflammation  during  the  develop- 
ment of  lactation  give  a  brisk  saline,  and  if  the  breasts  are  too  fiiU, 
empty  by  the  infant,  pump  or  massage.  If  the  pain  and  inflamma- 
tion continue,  apply  lead-water  and  laudanum  and  mammary  binder. 
Mammaiy  abscess  is  always  septic  in  origin,  and  should  be  consid- 
ered in  every  case.  To  prevent  it,  the  nipple,  after  each  nursing, 
should  be  washed  with  soap  and  water,  and  sweet  oil  applied.  In 
some  cases  astringents  may  be  used.  The  mammary  binder  is 
preferably  T-shaped,  one  arm  passing  around  the  back,  one-half  of 
the  remaining  arm  above,  the  other  below,  the  breasts,  and  the  two 
halves  brought  together  between  the  breasts. 

8.  The  Child. — Sleep,  cleanliness  and  regularity  in  feeding  should 
be  secured.  For  the  first  two  days  it  may  be  fed  every  three  hours, 
then  every  two  hours  during  the  day,  and  from  one  to  three  times  at 
night.     A  daily  bath,  90°  F. ,  should  be  given  at  nooij. 

Directions  to  Nurse. 

Before  Lahor 

I.  Have  ready  towels ;  ether  J  lb.  ;  brandy  (2  oz. ) ;  vinegar 
(4  oz.);  hot  water;  a  bottle  of  antiseptic  tablets;  a  large  new 
sponge  ;  a  roll  of  narrow  tape  ;  a  fountain  syringe  ;  bed-pan  ;  new, 
soft  rubber  catheter ;  4  clozen  pads,  small  package  of  salicylated 
cotton,  absorbent  cotten. 

II.  Grive  a  rectal  injection  as  soon  as  labor  pains  are  well  estab- 
lished. 

After  Labor. 

III.  No  vaginal  injection  to  be  given  unless  ordered. 

TV.  Take  the  temperature  three  times  a  day — morning,  noon 
and  evening. 

V.  Place  pad  wider  patient.  No  occlusive  bandage  to  be  used 
unless  specially  directed. 

VI.  The  external  genitals  to  be  washed  ofi"  four  or  five  times  a 
day  with  a  warm  corrosive  subhmate  solution  1-2000.  Use  absorbent 
cotton  for  this  purpose. 

VII.  If,  at  the  end  of  12  hours,  the  bladder  cannot  be  emptied 
naturahy,  use  a  catheter.  Afterward,  if  necessary,  catheterize 
patient  three  times  a  day. 


MECHANISM   OF   LABOR.  119 

VIII.  The  patient  is  to  lie  on  her  back  ;  she  may  be  moved 
from  one  side  of  the  bed  to  the  other  several  times  a  day  :  her  limbs 
may  be  rubbed  with  alcohol  and  water  or  bathing  whiskey  once  a 
day. 

IX.  The  Nurse's  hands  are  to  he  washed  in  a  1--3000  suhlimate 
solution  before  catheterizing  the  patient,  cleansing  the  genitals  or 
breasts. 

Diet. — First  ^8  hours. — Milk  (11-2.  pints  a  day),  gniel,  soup,  one 
cup  of  tea  a  day,  toast  and  butter. 

Second  ^8  hours. — Milk  toast,  poached  eggs,  ponidge,  soup,  com 
starch,  tapioca,  wine  jelly,  small  raw  oysters,  one  cup  of  coffee  or 
tea  a  day. 

Third  If8  hours. — Soup,  white  meat  of  fowl,  mashed  potatoes, 
beets  in  addition  to  above. 

After  sixth  day,  return  cautiously  to  ordinary  diet. 

Child. — I.  After  being  well  rubbed  with  sweet  oil,  the  child  is  to 
be  bathed  in  water  of  90°  ;  this  should  be  the  temperature  of  the 
daily  bath. 

II.  The  cord  is  to  be  dressed  with  salicylated  cotton.  Obsei-ve 
carefully  for  bleeding. 

III.  It  should  be  bathed  daily,  about  mid-day,  in  the  wai-mest 
part  of  the  room.    Use  castile  soap  and  a  soft  sponge  ;  avoid  the  eyes. 

TV .  The  bowels  of  a  healthy  infant  are  moved  4  times  a  day  ;  the 
diapers  must  be  changed  at  least  this  often.     Xote  the  color  of  stools. 

Nursing. — The  child  is  to  be  put  to  the  breast  eveiy  four  houi-s 
for  the  first  two  days.  No  other  food  is  to  he  given  it.  After  the 
second  day  it  should  be  nursed  every  two  hours,  fi-om  7  A.  m.  to 
9  P.  m.,  and  twice  during  the  night  (1  A.  m.  and  5  a.  m.).  After 
every  nursing  the  nipples  are  to  be  careftilly  washed  with  a  piece 
of  absorbent  cotton,  warm  water  and  castile  soap,  and  then  smeared 
with  a  little  sweet  oil. 


Mechanism  of  Labor. 

Definition. — The  manner  in  which  a  foetus  traverses  the  birth 
canal  and  is  expelled.  It  takes  into  account  the  complicated  struc- 
ture of  the  maternal  and  foetal  parts,  considering  their  movements 
and  the  mechaiiisms  of  their  motions. 


120  OBSTETRICAL  LECTURES. 

Presentation. — That  part  of  the  foetal  body  which  presents  itself 
to  the  examining  finger  in  the  centre  of  the  plane  of  the  superior 
strait. 

Position. — May  be  applied  to  the  position  of  the  child  in  utero, 
whether  longitudinal  or  transverse  ;  or,  in  another  sense,  it  is  the 
varying  relations  which  the  presenting  part  bears  to  the  surrounding 
maternal  structures  at  the  plane  of  the  superior  strait. 

Presentation  and  position  are  determined  by  abdominal  palpation, 
auscultation,  and  vaginal  examination.  Palpation  and  auscultation 
have  been  referred  to.  By  vaginal  examination  the  finger  detects 
the  varying  portions  of  the  foetal  body  which  may  jiresent  at  the 
superior  strait,  as  cranium,  face,  shoulder,  buttocks,  knees,  feet, 
and,  exceptionally,  elbow  or  hand. 

The  position  of  the  foetus  in  utero  is  longitudinal  in  99J  per  cent, 
of  all  cases.  The  cephalic  extremity  presents  in  about  95^^  per  cent. , 
95  per  cent,  being  vertex  cases.  In  about  J  of  1  per  cent,  the  face 
presents ;  the  brow  very  rarely.  In  about  3  per  cent,  of  all  cases 
the  breech  presents,  and  in  about  J  of  1  per  cent,  the  foetus  will  be 
transverse. 

Explanation  of  the  Great  Frequency  of  Cephalic  Presentations. — 
Assumption  of  that  position  by  the  foetus,  because  it  afibrds  it  the 
greatest  degree  of  comfort  and  the  best  opportunity  for  growth  and 
development. 

Explamation  of  the  Great  Frequency  of  Presentation  of  the  Vertex. 
— Mechanical  arrangement  of  foetal  head  and  body,  diagram  matically 
represented  by  two  bars  attached  to  one  another  ;  that  representing 
the  head  joined  to  that  representing  the  spinal  column,  not  at  its 
middle,  but  at  a  point  nearer  one  end  of  the  bar  (T).  An  equal 
force  exerted  upon  this  mechanical  arrangement  will  result  in  the 
greater  flexion  of  the  longer  bar,  which  represents  that  portion  of 
the  foetal  skull  in  front  of  spinal  column. 

Positions  of  Vertex  Presentations. — There  are  four  :  1.  L.  0.  A. , 
left  occipito-anterior,  the  occiput  looking  to  left  acetabulum.  2.  R. 
O.  A.  3.  R.  0.  P. ,  right  occipito-posterior,  the  occiput  looking  to 
right  sacro-iliac  joint.  4.  L.  0.  P.  Of  all  vertex  cases  70  per  cent, 
are  L.  0.  A. ,  30  -per  cent.  R.  0.  P. 

Explanation  of  Frequency  of  L.  0.  A.  and  R.  0.  P. — The  posi- 
sition  of  the  rectum  shortening  the  left  oblique  diameter  and  the 


MECHANISM   OF   LABOR.  121 

projectiuM  of  tlie  spinal  column  to  which  the  foetus'  adapts*its  ante- 
rior concave  surface,  the  back  thus  looking  forward  and  turned  a 
little  toward  the  right  because  of  the  right  lateral  version  of  the 
pregnant  uterus. 

Forces  Involved  in  the  Mechanism  of  Labor. 

1.  Forces  of  Expnhion : — 

Uterine  muscle. 
Abdominal  muscles. 

2.  Forces  of  ReMstance : — 

Lower  uterine  segment,  cervix,  vulva,  vagina. 

Pelvis. 

Foetal  bodJ^ 

The  forces  of  expulsion  are  furnished  hy  a  great  part  of  the 
uterine  muscle  (upper  uterine  segment)  and  muscular  action  of  the 
abdominal  walls.  (That  portion  of  the  uterine  canal  which  must  be 
dilated  to  allow  the  escape  of  the  foetus  is  called  the  lover  vteriue 
segment ;  that  portion  above  the  point  at  which  the  dilatation  ceases, 
?'.  e.,  the  contracting  muscle,  is  called  the  tipper  nterine  segment; 
the  boundary  line  between  these,  often  marked  hj  a  perceptible 
ridge,  is  called  the  contraction  ring). 

The  Manner  in  ivhich  the  Uterine  Muscle  Exerts  its  Force  upon  the 
Foetal  Body.  — By  a  diminution  of  the  intrauterine  area.  The  abdomi- 
nal muscles  diminish  the  area  of  intra-abdominal  space.  The  degree 
of  force  exerted  by  their  combined  action  has  been  given  as  fi'om  1 7 
to  55  pounds.  The  forces  of  resistance  are  famished  by  that  portion 
of  the  parturient  tract  which  must  be  dilated,  i.  e. ,  from  contraction 
ring  to  vulva,  including  {a)  the  lower  uterine  segment,  cervix,  vagina 
and  vulva.  The  dilatation  of  lower  uterine  segment  and  cervix  is 
not  simply  mechanical,  the  serous  infiltration  of  lymph  spaces  lessen- 
ing the  tendencj^  to  contraction  and  retraction.  The  dilatation  of 
cei-vical  canal  is  also  assisted  by  the  longitudinal  fibres  drawing  the 
cervix  up  over  the  presenting  part.  Below  the  cervix,  dilatation  is 
effected  mainly  hy  the  mechanical  stretching  of  its  walls. 

{}))  The  hony  walls  of  the  x>elvis. — Only  offer  sufficient  resistance 
to  so  delay  the  progress  of  presenting  part  as  to  insure  gradual  dila- 
tation of  the  soft  resisting  structures. 

(c)  Fmtal  hody. — Head  most  important.     The  foetal  head  maybe 


122  OBSTETRICAL  LECTURES. 

divided  -into  yielding  and  unyielding  portions.  The  yielding  con- 
sists of  the  cranium,  composed  of  the  frontal  (2),  temporal  (2), 
parietal  (2),  and  occipital  bones.  These  are  separated  from  one 
another  as  follows :  The  two  frontals  by  the  frontal  suture ;  the 
frontal  from  parietal  by  coronal  suture  ;  the  two  parietal  by  sagittal 
suture  ;  the  two  parietal  from  occipital  by  the  lambdoidal  suture. 
At  junction  of  lambdoidal  and  sagittal  sutures  there  is  a  membranous 
space  called  the  posterior  fontanelle,  triangular  in  shape.  At  junc- 
tion of  frontal,  coronal  and  sagittal  sutures  there  is  also  a  mem- 
branous space  called  anterior  fontanelle,  kite-shaped,  larger  than  the 
former.  This  portion  of  the  skull  yields  by  overlapping  of  the 
bones. 

The  unyielding  portion  comprises  face  and  base  of  skull.  The 
bones  here  are  fixed. 

A  transverse  vertical  section  of  the  skull  is  wedge-shaped,  taper- 
ing toward  the  neck. 

Possible  Presentations  of  tlie  Head. —  Vertex.  That  conical  por- 
tion with  apex  at  smaller  fontanelle  and  base  at  the  plane  of  the 
biparietal  and  trachelo-bregmatic  diameters.  Face.  Brow.  Larger 
Fontanelle.     Parietal  Eminence. 

Mechanism  of  the  Several  Presentations  and  Positions. 

L.  0.  A. 

Diagnosis. — By  abdominal  palpation,  auscultation  and  vaginal 
examination,  the  back  is  found  to  the  left,  extremities  to  the  right 
above,  head  below,  heart  sounds  one  inch  below  and  to  the  left  of 
umbilicus ;  the  examining  finger  detects  vertex  presenting,  occiput 
toward  left  acetabulum  and  sagittal  suture  in  right  oblique  diameter 
of  pelvis,  and  smaller  fontanelle,  recognized  by  the  junction  of  lamb- 
doid  and  sagittal  sutures,  the  top  of  occipital  bone  overlapped  by 
parietal  bones. 

1st  Stex>.  — Accommodation  of  size  of  foetal  skull  to  pelvis  by  flexion, 
and  accommodation  of  shape  of  foetal  skull  to  shape  of  pelvic  inlet 
by  moulding.     (Occurs  before  the  onset  of  labor.) 

2d  Step. — Further  flexion  and  moulding.  (Occurs  at  the  begin- 
ning of  labor. ) 

3d  Step. — Lateral  flexion  of  the  head,  the  right  parietal  bone 
presenting. 


MECHANISM   OF   LABOR.  123 

Ii.th  >SVe/).— Dilatation  of  lower  uterine  cavity  and  cervical  canal. 

5th  iS'^ep.— Descent  of  head  to  pelvic  floor. 

6tli  Step. — Anterior  rotation  of  occiput.  Cause. — The  head 
driven  through  the  funnel-shaped  parturient  canal  and  meeting  the 
resisting  pelvic  floor  moves  in  the  direction  of  least  resistance,  i  e. , 
anteriorly  t(jward  median  line. 

7th  Step. — Extension  and  propulsion  of  the  head. 

8th  Step. — Restitution. 

9fh  Step. — External  rotation. 

10th  Step. — Descent,  rotation  and  birth  of  shoulders. 

11th  Step. — Delivery  of  remainder  of  the  body. 

Abnormalities. 

(a)  Flexirm  at  Inlet. — Imperfect  vertical  flexion  in  flat  pelvis. 
Conservative  on  the  part  of  nature  to  bring  bitemporal  diameter 
(8  cm.)  in  relation  with  contracted  conjugate.  Associated  with  this 
we  find  anomalies  of  position  and  lateral  flexion,  i.  e.,  the  occiput 
situated  transversely,  the  sagittal  suture  in  transverse  diameter  of 
the  pelvis  and  the  lateral  flexion  exaggerated  as  the  result  of  the 
increased  obliquity  of  pelvis  to  trunk  and  increase  of  conjugato- 
symphyseal  angle.  This  is  accompanied  by  overlapping  of  the  right 
(anterior)  parietal  bone. 

Q>)  Direction.  —In  anterior  displacements  of  the  pregnant  utems, 
there  is  an  abnormal  backward  direction  of  the  presenting  part. 

(c)  Rotation. — Abnormal  weakness  in    resistance   or   propulsion 
result  in  incomplete  rotation. 

{d)   Vertical  Flexion  at  OwtZe?.— Incomplete  when  head  does  not 
encounter  normal  resistance  in  pelvic  cavity. 

(e)  E:cte.nsion.—F-<\J\[viTQ  of  extension  of  the  head  occurs  as  the 
result  of  weakness  or  destruction  of  the  levatores  ani  muscles. 

(/)  ReMitution.—W\\^  when  neck  is  a  long  time  twisted  or  tightly 
gripped  by  the  vulva. 

{g)  External  Rotrxtion.—Due  to  failure  of  rotation  of  shoulders. 
Is  of  frequent  occurrence. 

(h)  Anomalous  Dejicent  and  Rotation  of  Shoulders. 


124  OBSTETRICAL  LECTURES. 

K  0.  A 

Diagnosis. — Palpation  reveals  back  to  the  right  anteriorly; 
extremities  to  the  left  above  ;  head  below.  Heart  sounds  near 
median  line  below  umbilicus.  Digital  examination  shows  small 
fontanelle  toward  right  acetabulum  ;  sagittal  suture  in  left  oblique 
diameter. 

MechanisTn. — Does  not  differ  from  the  mechanism  of  L.  0.  A., 
except  the  occiput  being  directed  toward  the  right  acetabulum, 
rotation  of  head  and  face  occurs  in  the  opposite  direction. 

K  0.  P.,  andL.  0.  P. 

Posterior  j^ositions  of  the  occiput  are  primary  or  acquired. 
Primaiy  when  head  enters  inlet  with  occiput  posterior  (common)  ; 
acquired  when  head  rotates  from  anterior  position  at  the  beginning 
of  labor  to  a  posterior  position  at  its  close  (rare). 

Diagnosis. — Palpation  reveals  back  in  the  flank  (right,  in  E,.  0. 
P.  ;  left,  in  L.  0.  P. ) ;  extremities  to  the  opposite  side  in  front ; 
head  below.  Heart  sounds  in  the  flank  below  a  transverse  line 
through  umbilicus.  Digital  examination  shows  small  fontanelle 
toward  right  or  left  sacro-iliac  joint  ;  sagittal  suture  in  an  oblique 
diameter. 

Meclianistn. — Similar  to  mechanism  of  anterior  positions  includ- 
ing anterior  rotation  of  the  occiput  to  symphysis.  As  a  consequence 
of  this  prolonged  rotation  a  peculiarity  is  the  rotation  of  the 
shoulders  at  the  superior  strait  through  a  quarter  of  a  circle,  a 
movement  not  seen  in  anterior  positions,  and  in  consequence  of  the 
greater  distance  which  the  occiput  has  to  traverse  the  clinical  mani- 
festations of  this  stage  are  different,  i.  e. ,  there  is  greater  pain  and 
labor  is  more  prolonged.  After  rotation  has  occurred  the  shoulders 
descend  and  rotate  on  the  pelvic  floor,  as  in  anterior  positions.  The 
ftirther  mechanism  is  identical  with  that  of  anterior  positions. 

Cause  of  Forward  Rotation  of  Occiput.  —  Same  as  in  anterior 
positions,  i.  e. ,  whatever  portion  of  the  foftal  head  first  .strikes  the 
pelvic  floor  .^  whether  it  encounters  this  structure  behind  or  in  front  of 
the  median  transverse  line.,  will  he  directed  forward  under  the  sym- 
physis pubis. 


mechanism  of  labor.  125 

Abnormalities  in  Mechanism. 

Backward  Rotation  of  the  Occiput  complicates  labor  by  protracting 
its  course,  increasing  the  danger  of  foetal  death,  and  subjecting  the 
mother  to  increased  risk  of  injury. 

Causes. — 1 .  Anomalies  of  Force. — Anterior  rotation  is  the  result- 
ant of  the  forces  of  expulsion  and  resistance,  hence  any  condition 
disturbing  the  normal  relation  of  these  forces  will  interfere  with  the 
normal  rotation.  Thus  backward  rotation  occurs  when  there  is 
diminished  expulsion,  increased  resistance,  or  decrease  in  resistance 
as  occurs  in  cases  of  very  large  pelves,  relaxed  pelvic  floors,  small 
and  yielding  heads. 

2.  Anomalies  of  Flexion. — When  flexion  is  imperfect  the  anterior 
vault  of  the  cranium  (as  in  those  rare  cases  of  presentation  of  the 
large  fontanelle),  the  brow,  or  chin  first  strikes  the  fjelvic  floor  and 
is  therefore  directed  forward,  and  the  occiput  thus  directed  back- 
ward. 

3.  Insuperable  Hinclramces  to  Forward  Rotation.  —  In  some 
cases  when  flexion  is  only  partially  disturbed  and  the  occiput 
first  strikes  the  pelvic  floor,  the  occiput  will  rotate  backward, 
because  the  large  diameter  of  the  head  (fronto-occip.  llf  cm.) 
engages  and  rotation  from  one  oblique  diameter  of  the  pelvis, 
through  the  smaller  transverse  to  the  other  oblique,  is  impossible. 
The  occiput  will  also  be  directed  backward  for  the  same  reason  when 
the  foetal  head  is  over  size,  or  accompanied  by  a  prolapsed  extrem- 
ity ;  when  the  pelvis  is  deformed,  particularly  kyphotic,  generally 
contracted  and  Naegele's  ;  when  there  is  an  abnormal  projection 
of  the  lumbar  and  sacral  vertebrae  interfering  with  rotation  of 
shoulder. 

Mechanism  when  Occiput  Rotates  into  Hollow  of  Sacrum. — The 
occiput  is  propelled  forward  over  perineum  by  increased  flexion 
until  the  face  is  finally  born  under  the  symphysis  by  partial  exten- 
sion. This  mechanism  subjects  the  cranium  of  the  foetus  to  danger- 
ous pressure,  and  increases  the  danger  of  perineal  rupture. 

Abnormalities  in  Mechanism  just  Descnbed. — x^bnormal  resistance 
to  de.scent  of  occiput,  resulting  in  conversion  into  jDresentation  of 
large  fontanelle,  brow,  or  face. 

Causes. — Projecting  ischiac  spines,  central  tear  of  perineum. 


126  obstetrical  lectures. 

Treatment  of  Posterior  Positions  of   Vertex  Presenta- 
tions. 

Bear  in  mind  tlie  causes  of  rotation  backward,  and  try  to  prevent 
its  occurrence,  {a)  Secure  perfect  flexion  of  the  head  hy  placing 
patient  on  that  side  toward  which  the  foetal  back  is  looking,  {b) 
Secure  normal  action  of  expelling  and  resisting  f3rces.  If  the  pelvic 
floor  is  weakened  and  does  not  supply  sufficient  resistance,  reinforce 
it  by  two  fingers  in  tbe  vagina  or  single  blade  of.  forceps.  If  expul- 
sion is  faulty  administer  a  single  large  dose  of  quinine,  or  forceps 
may  be  resorted  to.  If  backward  rotation  occurs  in  spite  of  preven- 
tive treatment,  extra  precautions  should  be  made  to  protect  vaginal 
walls  and  perineum  from  laceration,  and  to  avoid  a  protracted  second 
stage.  These  can  usually  be  accomplished  by  judicious  use  of  for- 
ceps. It  may  be  necessary  rarely  to  first  convert  into  a  face  presen- 
tation. 

Prognosis. — Not  so  favorable  as  in  anterior  positions  of  occiput. 
Forceps  often  required.  Laceration  of  soft  parts  more  frequent. 
The  mortality  of  the  foetus  increased  from  5  per  cent,  (normal 
vertex),  to  over  9  per  cent.  Luckily  backward  rotation  occurs  in 
only  about  IJ  per  cent,  of  all  labor  cases. 

Face. 

The  bead  is  extremely  extended.  The  chin  is  the  most  dependent 
part  presenting,  hence  the  classification  by  its  situation,  left  mento- 
anterior, right  mento-anterior,  etc. 

Frequency. — Occurs  about  once  in  250  labor  Cases. 

Diagnosis. — Bulk  of  cranial  vault  felt  to  one  side  of  hypogastric 
region  ;  a  deep  groove  between  occiput  and  the  child's  back  may 
sometimes  be  made  out.  Heart  sounds  loudest  over  anterior  surface 
of  foetus,  i.  e. ,  on  that  side  of  abdomen  upon  which  the  extremities 
are  felt.  The  diagnosis,  however,  must  usually  rest  on  digital  exami- 
nation, which  shows  before  onset  of  labor  high  situation  of  present- 
ing part  ;  flattening  of  anterior  vaginal  vault ;  the  contrast  between 
the  smooth  outline  of  foetal  forehead  and  irregular  contour  of  the 
face.  As  soon  as  the  os  is  dilated  the  characteristic  features  of  the 
face  can  be  felt.  Has  been  mistaken  for  the  breech.  Should  be 
considered  an  abnormality  and  entails  greater  danger  upon  mother 
and  child. 


MECHANISM   OF   LABOR.  127 

Cames. — Conditions  preventing  flexion,  as  tumors  of  the  neck; 
increased  size  of  thorax ;  constriction  of  cervix  about  the  neck  ; 
coiHng  of  cord  around  neck. 

Conditions  favoring  extension,  as  mobiht}^  of  foetus  ;  obHque  posi- 
tion of  child  and  uterus,  especially  when  abdominal  surface  of  child 
is  directed  downward  and  pelvis  is  flat :  altered  shape  of  head. 
After  the  head  has  reached  the  pelvic  cavity  it  may  be  due  to  the 
conversion  of  an  occipito-posterior  position  into  that  of  the  face,  as 
already  described, 

Meckaniwi. — Comprises  the  following  steps  : — 

1.  Extension. 

2.  Moulding. 

3.  Descent. 

4.  Anterior  rotation  of  cliin, 

5.  Its  engagement  under  symphysis  pubis. 

6.  Delivery  of  head  by  flexion. 

7.  Restitution. 

8.  External  rotation. 

9.  Delivery  of  body  as  in  vertex  presentation. 
Ahnormalities   in   Mechanism. — The   most  common   is   delay  in 

forward  rotation  of  chin  under  symphysis.  This  is  due  to  the  differ- 
ence between  the  lateral  depth  of  the  pelvis  (3J  inches),  and  the 
length  of  the  foetal  neck  (U  inches),  /.  e.,  the  chin  does  not  meet 
with  sufficient  resistance.  Should  the  chin  be  directed  posteriorly, 
where  the  depth  of  the  pelvis  is  even  greater,  the  delay  is  absolute, 
and  such  cases  can  only  be  terminated  by  artificial  assistance.  If  left 
to  nature  the  upper  portion  of  thorax  (9  cm. )  is  forced  into  the  pel- 
vic cavity,  along  with  the  posterior  half  of  the  child's  skull  (9J  cm.), 
and  it  is  impossible  for  these  two  diameters  to  pass  through  the 
pelvis. 

P/-o,^?io.svs.— Foetal  mortality  13  to  15  percent.  Maternal,  from 
less  than  1  to  6  per  cent. 

Treatment.  — Before  labor  begins,  convert  into  vertex  by  the  method 
of  Schatz.  If  this  fails  and  labor  is  in  progress,  guard  against  rup- 
turing the  membranes,  that  the  os  may  be  more  thoroughly  dilated 
and  the  liquor  amnii  not  drained  away.  If  anterior  rotation  of  the 
chin  is  delayed,  it  may  be  hastened  by  two  fingers  pressing  on  the 
cheek  and  chin  ;  or,  if  necessary,  pressure  may  be  applied  with  a 


128  OBSTETRICAL  LECTURES. 

single  blade  of  the  forceps.  These  failing,  straight  forceps  may  be 
used  to  effect  rotation,  and  if  the  chin  is  directed  anteriorly  traction 
may  be  made.  If  the  chin  is  directed  backward  traction  should  not 
be  employed.  Finally,  craniotomy  may  be  necessary.  When  the 
case  progresses  with  or  without  assistance  care  must  be  exercised  in 
the  final  delivery  of  the  head,  not  to  push  the  neck  too  forcibly 
against  symphysis  when  trying  to  prevent  laceration  of  the  peri- 
neum. 

Brow. 

Head  midway  between^complete  extension  and  complete  flexion. 
The  largest  diameter  of  the  head  presents.     Of  all  presentations  of 
the  head  it  is  the  most  unfavorable  for  mother  and  child.     The  four 
positions  are  classified  according  to  the  direction  of  the  chin. 

Diagnosis. — Is  made  by  a  digital  examination. 

Mechanism.  — The  steps  are  similar  to  those  of  face  presentation. 
When  the  chin  is  directed  posteriorly  the  case  is  an  impossible  one 
for  the  same  reason  as  in  the  posterior  position  of  the  face. 

Prognosis. — Foetal  mortality,  30  per  cent.  ;  maternal,  10  per  cent. 

Treatment. — Before  labor  convert  into  vertex.  This  can  some- 
times be  accomplished  by  external  pressure  on  the  occiput  to  secure 
flexion.  If  this  fails,  insert  hand  in  the  vagina  and  pull  occiput 
down.  Next,  try  to  convert  into  face  if  the  chin  is  anterior.  If 
this  fails,  version  should  be  tried.  It  should  not  be  resorted  to  if  the 
waters  are  drained  off,  or  the  presenting  part  is  fixed  in  the  superior 
strait.  Finally,  if  the  chin  is  anterior,  apply  forceps  ;  if  posterior, 
craniotomy  is  indicated.  In  face  and  brow  presentations  the  cardi- 
nal rule  is,  not  to  use  forceps  except  as  rotators ;  if  traction  is 
resorted  to  at  all,  it  should  be  employed  with  the  greatest  caution 
and  gentleness.  Very  rarely  the  head  may  be  brought  down  far 
enough  to  meet  with  resistance,  and  thus  be  rotated  anteriorly, 
but  unless  the  head  yields  to  moderate  traction,  embryotomy  is  pre- 
ferable. 

Breech. 

Presentation  of  any  part  of  the  pelvic  extremity  of  the  foetal 
ellipse.  The  classification  is  according  to  the  direction  of  the  sacrum, 
left  sacro-anterior,  right  sacro-anterior,  etc. 

Frequency. — Occurs  in  3  to  4  per  cent,  of  all  cases. 


MECHANISM   OF   LABOR.  129 

Causes. — ].  Abnormalities  in  shape  of  foetus  or  uterine  cavity. 
Includes  reversal  of  uterine  ovoid  (the  lower  uterine  segment  larger 
than  upper) ;  foetal  monstrosities  ;  twin  pregnancy  (in  25  per  cent, 
of  cases  the  breech  presents).     2.  Increased  mobility  of  the  foetus. 

Diagnosis. — Head  above,  breech  below.  Heart  sounds  are  heard 
on  a  transverse  line  above  umbilicus.  Digital  examination  shows 
high  position  of  the  presenting  part  ;  absence  of  dome-like  projec- 
tion of  vaginal  vault  which  is  found  in  presentation  of  head  ;  the 
bag  of  waters  projects  as  a  pouch-like  protrasion ;  by  pressure  on 
the  fundus  with  the  other  hand  the  characteristic  features  of  the 
breech  may  be  detected,  ^,  e. ,  the  nates  and  sulcus  between  them, 
tip  of  sacral  bone  and  coccj^,  the  thighs,  external  genitalia  and 
anus,  evacuation  of  meconium,  which  in  breech  cases  is  not  of 
serious  import. 

Mechanism. — Comprises  the  following  steps  : — 

1.  Descent  of  breech  to  pelvic  floor.  Occurs  veiy  slowly  because 
the  soft  breech  is  an  ineffectual  dilator  of  the  cervix  and  ineffectual 
irritator  of  reflex  uterine  contraction,  hence  many  hours  may  be 
required. 

2.  Rotation  forward  of  anterior  hip.  The  anterior  hip  first  stiikes 
the  pelvic  floor,  but  owing  to  the  insufl&cient  resistance  which  the 
soft  breech  encounters  the  rotation  is  imperfect. 

3.  Birth  of  anterior  hip,  posterior  hip,  thighs  and  trunk. 

4.  Engagement  and  descent  of  shoulders  in  oblique  diameter. 

5.  Rotation  foi-ward  of  anterior  shoulder. 

6.  Birth  of  anterior  followed  by  posterior  shoulder. 

7.  Descent  of  head  in  oblique  diameter. 

8 .  Rotation  forward  of  occiput,  which  is  always  the  part  to  first 
strike  the  pelvic  floor. 

9.  Delivery  of  head  in  the  following  order  :  Chin,  face,  forehead, 
anterior  fontanelle. 

Prognosis. — Foetal  mortahty  30  per  cent.,  including  badly  man- 
aged cases. 

TrexLtment.  —Before  labor,  external  version.  After  labor  has  be- 
gun, inaction  until  body  is  born  to  umbilicus,  unless  maternal  or 
foetal  life  threatened.  At  this  time  interfere  and  deliver  by  press- 
ing upon  fundus  with  one  hand,  the  other  hand  in  the  vagina  to 

y 


130  OBSTETRICAL  LECTURES. 

favor  anterior  rotation  of  the  shoulder,  flexion  of  the  head,  and  to 
direct  the  head  through  the  vagina. 

Abnormalities  in  Mechanism. — The  most  frequent  and  important 
are  (1)  backward  rotation  of  the  occiput  and  (2)  excessive  rotation 
of  the  breech.  Backward  rotation  of  the  occiput  is  very  excep- 
tional, and  the  mechanism  now  difi"ers  as  the  head  remains  flexed  or 
becomes  extended.  When  flexed,  the  chin,  face,  forehead,  anterior 
fontanelle  slip  out  under  symphysis  in  the  order  named,  and  the 
head  is  delivered.  When  extended,  the  chin  catches  upon  the 
symphysis,  the  head  is  extremely  extended  and  is  born  by  the  oc- 
cipital protuberance,  small  fontanelle,  cranial  vault  and  face  slipping 
over  the  perineum.  The  following  rules  for  managing  these  cases 
should  be  remembered  :  If  flexed,  the  body  of  the  child  should  be 
carried  downward.  If  extended,  the  body  should  be  carried  up- 
ward over  the  mother's  abdomen.  Excessive  rotation  of  the  breech 
occurs  as  the  result  of  prolapse  of  posterior  extremity,  and  is  of  no 
great  practical  importance. 

Shoulder. 

Transverse  position  of  the  child  in  utero  resolves  itself  into  a 
shoulder  presentation  as  the  result  of  uterine  contraction  when  labor 
begins.  Shoulder  presentations  are  classified  according  to  the  posi- 
tion of  the  back  and  head.  When  the  head  is  to  the  right,  the 
back  can  be  in  front  or  behind.  The  same  is  true  when  the  head  is 
to  the  left.  The  back  is  directed  anteriorly  twice  as  often  as  poste- 
riorly, and  the  head  more  than  twice  as  often  is  found  toward  the 
left. 

Diagnosis. — Abdominal  palpation  reveals  the  foetus  in  a  trans- 
verse position.  The  heart-sounds  are  more  distinct  at  a  point  cor- 
responding to  the  interscapular  region  of  the  child,  and  sometimes 
cannot  be  heard.  Digital  examination  shows  the  characteristics  of 
the  shoulder,  viz.,  axilla,  clavicle,  spine  of  scapula,  acromion  pro- 
cess, head  of  the  humerus,  ribs. 

Causes.  — 1 .  Abnormalities  in  the  shape  and  position  of  the  uterus, 
as  pendulous  abdomen  ;  uterus  bicornis ;  kyphotic  spine ;  uterine 
fibroid  and  other  abdominal  tumors  ;  multiple  pregnane}^  (in  twin 
pregnancies  the  shoulder  presents  once  in  22  cases). 


OBSTETRIC   OPERATIONS.  131 

2.  Conditions  preventing  engagement  of  ceijhalic  or  pelvic  ex- 
tremity, as  deformity  of  the  pelvis  ;  abnormally  large  child  ;  mon- 
strosities ;  placenta  praevia. 

3.  Abnormal  mobility  of  the  foetus,  as  occurs  in  hydramnion, 
after  fcetal  death,  or  in  premature  birth. 

Mechanism. — Strictly  speaking,  there  is  no  mechanism  of  shoulder 
presentations.  The  course  of  these  cases  is  impaction  of  the  shoulder, 
ascension  of  contraction  ring,  death  of  the  mother  by  rupture  of  the 
uterus  or  exhaustion,  and  destruction  of  the  foetus  by  prolonged 
pressure.  As  a  matter  of  ftict,  however,  nature  can  in  exceptional 
cases  effect  delivery  in  one  of  three  methods  : — 

1.  Spontaneous  version.  The  transverse  position  converted  into 
a  longitudinal  by  uterine  contraction. 

2.  Spontaneous  evolution.  The  breech  slips  past  the  shoulder 
and  is  delivered. 

3.  Body  doubled  up  (corpore  reduplicate). 
Treatment.  — Version. 


Obstetric  Operations. 

Induction  of  Premature  Labor  and  Abortion. 

Abortion. 
When  performed  before  viability  of  child  (180th  day). 
Indications.— When  the  patient  is  a  subject  of  disease  originating 
in  or  aggravated  by  pregnancy,  and  life  endangered  thereby,  viz.  :— 

1.  Pathological  Vomiting. — Only  after  all  known  remedies  and 
rectal  alimentation  fail. 

2.  Grave  Albuminuria. — As  when  oedema,  headache,  casts,  etc., 
threaten  eclampsia. 

3.  Certain  Nervous  Diseases. — As  acute  mania,  melancholia,  or 
associated  inflammatory  changes  in  the  brain.     Rarely  chorea. 

4.  Certain  Blood  Diseases. — Pathological  hydraemia  (pernicious 
anaemia),  leucocythemia. 

5.  Displacements  of  Gravid  t^/'eras.— Retroflexion,  prolapse,  her- 
nia, resisting  other  treatment. 

Always  secure  consultation  and  share  responsihility. 


132  OBSTETRICAL  LECTURES. 

Methods. — Many  have  been  resorted  to,  but  have  been  found 
either  too  dangerous,  slow,  or  ineffectual.  Such  are  the  use  of 
ergot,  cotton-root,  injections  upon  cervix  or  between  membranes, 
inflated  rabber  bags  in  vagina  or  uterus,  rapid  or  gradual  dilatation 
of  the  cervix,  perforation  of  the  membranes. 

The  method  recommended  is  a  combination  of  the  good  features 
of  some  of  those  mentioned,  and  is  as  follows  : — 

1st.  Disinfect  canal  by  antiseptic  douche  and  pledget  of  mercurial- 
ized cotton  in  cervix. 

2d.  Dilate  cervix  to  size  of  thumb  with  Hegar's  dilators. 

3d.  Antiseptic  wool  tampon  in  cervix  and  lower  uterine  segment, 
and  a  similar  tampon  in  vagina.  Remove  at  the  end  of  8  hours. 
If  the  ovum  is  not  discharged  from  the  uterus,  remove  it,  using, 
with  strict  antiseptic  precautions,  the  finger,  or  with  greatest  care, 
curette. 

Premature  Labor. 

When  performed  after  viability  of  child. 

Indications. — 1.   For  diseases  as  above. 

2.  Special  Indications.,  as  («)  Contracted  Pelvis,  (b)  Advanced 
Phthisis,  Grrave  Heart  Disease,  etc.,  threatening  mother's  life,  (c) 
Habitual  Death  of  Foetus  just  before  term. 

Method. — Sims'  position,  aseptic  hard  rubber  bougie  passed  in 
for  7  or  8  inches  between  deciduse  vera  and  reflexa.  Labor  begins 
after  a  variable  period,  3  hours  to  a  wieek,  the  average  being  36 
hours.  If  the  mother's  condition  demand  immediate  deliveiy,  the 
method  is  as  follows : — (a)  perforate  the  membranes,  {h)  forced 
dilatation  of  cervix  with  Barnes'  bags  or  Hegar's  dilators,  (c)  for- 
ceps, or  version  and  extraction. 

Forceps. 

Uses  and  Functions. 

{a)  Tractor — most  important. 

(6)  Eotator. 

(c)  Lever. 

(cZ)  Compressor — dangerous. 
Indications . 

1 .  Anomalies  in  Expulsive  Forces — as  uterine  or  abdominal  inertia. 

2.  Anomalies  in  Resistance — in  the  pelvis,   soft   parts  or  foetal 


OBSTETRIC   OPERATIONS.  133 

body,  as  minor  degrees  of  contracted  pelvis,  abnormal  rigidity  or 
large  foetal  head. 

3.  Threatened  F(jetal  Life — as  prematurely  detached  placenta, 
compression  or  prolapse  of  the  cord,  prolonged  pressure  on  foetal 
head,  feebleness  of  foetal  heart,  sudden  death  of  mother.  If  the 
heart  sounds  sink  to  100  for  a  mirmte  forceps  should  be  applied. 

4.  DebiUtatmg  diseases^  acute  or  chronic^  rendering  the  ordinary 
forces  insujjicient — as  phthisis,  tj'l^hoid,  heart  disease,  etc.  In  such 
the  forceps  should  be  applied  at  the  beginning  of  the  second  stage 
to  avoid  asphyxia  or  to  save  the  mother's  strength. 

5.  Life  Endangered — as  in  heart  clot,  eclampsia,  hemorrhage, 
rupture  of  uterus. 

6.  Abnormal  Positions  and  Presentations  and  Anomalies  in  the 
Mechanism  of  Lahor. 

As  a  general  rule,  they  should  be  applied  when  the  head,  during 
the  second  stage,  has  been  stationai-y  for  two  hours. 
Contraindications  : — 

1.  Os  must  be  dilated.  Exception.  When  maternal  or  foetal 
life  is  threatened,  it  is  allowable  to  apply  them  to  a  partially  dilated 
OS,  as  when  rupture  of  the  uterus  is  threatened,  as  shown  by  the  ap- 
proach to  the  umbilicus  of  the  groove  over  the  contraction  ring. 

2.  Head  must  have  engaged  at  the  superior  strait.  Exception. 
To  bring  head  down  as  a  tampon  in  marginal  placenta  praevia. 

3.  Membranes  must  be  ruptured. 

4.  Must  not  be  used  as  tractors  in  faulty  positions. 

5.  Should  not  be  emjployed  unless  head  be  of  average  size.  If  too 
small  or  too  large,  apt  to  slip  and  lacerate  the  soft  parts. 

6.  Shoidd  not  be  employed  ivhen  the  disproportion  between  the 
head  and  canal  is  too  great. 

Forceps  in  Contracted  Pelves. — Two  factors,  size  of  foetal  head 
and  degree  of  contraction,  must  be  considered  to  determine  between 
the  use  of  forceps  at  term  and  induction  of  premature  labor.  The 
determination  of  the  size  of  the  foetus  must  be  left  to  each  indi- 
vidual's skill  and  experience  in  abdominal  palpation.  In  contracted 
pelvis,  if  justo-minor,  with  conjugate  9 J  cm.,  or  over,  it  is  justifiable 
to  deliver  with  forceps  at  term .  If  the  conjugate  be  less  than  9^, 
induce  labor  preferably  at  36th  week. 

In  the  simple  flat  or  rachitic  flat,  9  cm.  is  the  limit  in  primiparaB  ; 


134  OBSTETRICAL  LECTURES. 

9i  cm.  in  multiparse,  whose  uterine  and  abdominal  forces  are  not 
so  strong  as  in  primiparae,  and  in  whom  rupture  of  uterus  is  more 
apt  to  occur. 

Forceps  Recommended. — Simpson,  for  the  low  operation,  Poullet 
V.  Hecker  or  Tarnier,  for  the  high  operation.  Sawyer's,  to  protect 
perineum  as  the  head  emerges. 

Rules  for  Apx>lication. — In  using  the  Simpson  forceps,  the  left 
blade  is  always  applied  first.  The  left  blade  should  be  held  in  the 
left  hand  and  introduced  into  the  left  side  of  the  pelvis.  Right 
blade  right  hand,  right  side  of  pelvis. 

With  the  diagnosis  of  the  presentation  assumed,  the  steps  in  the 
application  of  the  blades  may  be  summarized  as  follows : — 

1 .  Having  introduced  two  fingers  of  the  right  hand  into  the  vagina, 
the  left  blade,  grasped  at  the  lock  by  the  left  hand  as  a  pen,  is  held 
almost  perpendicularly,  with  the  tip  of  the  blade  opposite  the  vulva. 

2.  The  tip  of  the  blade  should  enter  the  vagina  and  traverse  the 
perineum  toward  the  sacrum. 

3.  Rotate  the  blade  outward  in  its  long  axis,  to  bring  it  in  apposi- 
tion with  the  posterior  inclined  plane  of  the  pelvis,  and  thus  escape 
the  promontoiy  of  the  sacrum  when  the  handle  is  depressed. 

4.  Depress  the  handle,  carrying  it  to  the  left  side,  the  fingers  of 
the  right  hand  in  the  vagina  guiding  the  blade  and  protecting  the 
soft  parts. 

5.  Introduce  the  right  blade  in  a  similar  manner,  substituting  right 
for  left  in  the  above  description. 

6.  To  grasp  the  head  properly  and  facilitate  locking,  rotate  for- 
ward the  Hght  blade  in  the  first  and  third  positions,  the  left  in  the 
second  and  fourth. 

Too  great  compression  of  the  head  may  be  avoided  by  placing  a 
folded  towel  between  the  handles.  Tractions  should  be  made  in  a  line 
parallel  to  the  axis  of  the  parturient  canal — with  the  pains  when 
present,  at  corresponding  intervals  when  absent.  During  the  inter- 
vals between  the  tractions  the  grip  on  the  handles  should  be  relaxed 
to  release  the  head  fi-om  compression.^ 

*  The  skill  and  manual  dexterity  required  in  all  forceps  operations  can  only 
be  acquired  by  actual  practice,  bence  the  student  must  avail  himself  of  the 
opportunity  to  learn  the  technique  of  all  the  operations  in  the  Laboratory  of 
Operative  Obstetrics. 


OBSTETRIC   OPERATIONS.  135 

Preliminaries  to  the  Operation.  — An  anaesthetic  always  renders  the 
operation  less  difficult.  The  lithotomy  position  at  the  edge  of  the 
bed  is  the  most  convenient.  The  blades  should  be  immersed  in  a 
5  per  cent,  solution  of  carbolic  acid  or  boiling  water,  rubbed  with  a 
50  per  cent,  solution  of  carbolic  acid  in  glycerine  and  folded  in  a 
clean  towel.  Just  before  using  them  vaseline  should  be  applied  to 
their  outer  surfaces. 

Version. 

Version  is  an  operation  or  manoeuvre  to  change  the  position  of  the 
foetus  in  utero. 
Varieties  : — 

(a)  Version  by  the  head  (cei)halic). 
{h)  Version  by  the  breech, 
(c)  Podalic. 


jb 


Methods 


(a)  Postural. 

(b)  External  manipulation. 

(c)  Internal  manipulation. 
{d )  Combined  or  Bi-polar. 

Indications  for  Version. 

1.  Presentations  of  the  trunk — usually  shoulder. 

2.  Deformity  of  pelvis. 

3.  Sudden  dangers,  when  the  head  is  not  engaged,  as  eclampsia, 
heart  clot,  etc. 

4.  Malpositions  of  the  head,  as  presentations  of  the  ear,  parietal 
bone,  brow  or  face. 

5.  Placenta  praevia. 

6.  Prolapse  of  cord. 

In  all  cases  combined  version  should  be  tried  first,  followed  by 
podalic  if  combined  fails. 
Contraindications : — 

1 .  The  presenting  part  should  not  be  engaged  nor  out  of  os. 

2 .  High  position  of  contraction  ring. 

Conditions  rendering  the  operation  difficult.,  dangerous,  or  impos- 
sible : — 

(a)  An  undilated  and  undilatable  vagina. 

(b)  A  similar  condition  of  cervix,  as  in  placenta  praevia,  where 


136  OBSTETRICAL  LECTURES, 

the  operation  is  performed  early.    Always  anaesthetize  and  overcome 
the  rigidity  gradually. 

(c)  Inability  to  effect  an  entrance  into  the  uterus,  as  occurs  when 
the  liquor  amnii  has  been  lost  and  the  uterus  is  retracted,  when  the 
uterus  is  permanently  contracted  (tetanus  of  uterus  so  called),  or 
when  there  is  obstruction  by  the  foetus,  as  hydrocephalus,  spina 
bifida  with  meningocele. 

{d )  Inability  to  bring  the  feet  down  after  they  are  grasped. 

(e)  Conditions  interfering  with  external  hand,  as  excessive  amount 
of  fat  in  abdominal  wall,  hysteria,  chorea,  epilepsy,  eclampsia. 

Conditions  3Iost  Favorable  for  the  Operation. — 
{a)  Uterus  distended  by  liquor  amnii. 
(h)  Os  dilated. 

(c)  Uterine  muscles  not  irritable. 

(d)  Abdominal  muscles  flexible  and  thin. 

(e)  Cervix  not  rigid. 

Postural. — This  method  msij  be  used  in  deviated  vertex  presenta- 
tions. Ear  presenting,  turn  the  patient  on  the  side,  so  that  breech 
may  face  to  that  side  and  thus  bring  vertex  over  os.  Brow  present- 
ing, turn  to  that  side  toward  which  the  face  looks,  and  thus  secure 
flexion  and  cause  veitex  to  present. 

Combined. — The  patient  should  be  placed  in  the  lithotomy  posi- 
tion and  anaesthetized.  Externally  use  the  hand  nearest  the  part 
acted  upon,  operator  facing  the  mother. 

Head  is  preferably  brought  to  superior  strait  because  it  is  usually 
nearer  centre  of  pelvis,  is  more  easily  manipulated  externally  and 
vertex  presentation  most  favorable  to  foetus. 

Podalic. — Preliminaries:  {a)  Secure  relaxation  of  uterus  and 
abdominal  muscles  by  anaesthetic,  (b)  Secure  lowest  position  of 
foetal^  feet  by  turning  mother  on  that  side  toward  which  the  feet 
point,  (c)  Use  that  hand,  made  aseptic,  which  midway  between  pro- 
nation and  supination  corresponds  to  abdomen  of  the  child.  The 
hand  reaches  the  anterior  foot  first,  and  the  advantages  of  resting 
content  with  traction  on  a  single  foot  are  : — 

{a)  A  further  entrance  into  uterus  is  unnecessary. 

(b)  Easier  to  hold. 

(c)  The  other  doubles  up  along  the  abdomen  and  thus  dilates  cer- 
vix more  thoroughly. 


OBSTETRIC    OPERATIONS.  137 

{d)  Secures  sacro-anterior  position  of  breech,  which  is  desirable. 
When  the  knee  is  born  cease  traction,  unless  there  exist  some 
indication  for  immediate  delivery,  stop  the  anaesthetic,  turn  the 
patient  on  her  back,  listen  to  foetal  heart-sounds  and  leave  the 
further  delivery  to  nature  until  the  head  is  about  to  be  born,  when 
it  should  be  extracted  by  the  following  methods,  in  the  order  given  : — 

{a)  Wiegand. 
{h)  Veit-Smellie. 
(c)  Prague. 
{d)  Forceps. 
Not  more  than  five  minutes  should  be  consumed  in  the  operation. 
When  rapid  delivery  of  breech  cases  maybe  required,  it  is  afcom- 
plished  by  means  of  the  fillet  or  flexible  blunt  hook. 

Embryotomy. 

Embryotomy  is  mutilation   of  the  foetus  and  comprises  several 
operations  : — 

{a)  Craniotomy. 
(Jj)  Decapitation, 
(c)  Evisceration. 
{d)  Amputation  of  extremities. 
Craniotomy. — Comprises  opening  the  head,  diminishing  its  size, 
and  its  extraction. 

Indications  ivhen  the  Child  is  Dead. — When  the  mother  can  be 
saved  risk  or  sufiering  by  the  child's  deliver3^ 
Indications  when  the  Child  is  Living. 

(a)  When  the  head  is  very  large. 
{h)  When  the  pelvis  is  very  small. 
Many  authors  advise  the  operation  when  the  conjugate  measures 
6-8  cm. ,  but  the  size  of  the  head,  its  compressibility  and  the  muscu- 
lar power  of  the  woman  are  elements  to  be  considered.     Premature 
labor,  when  possible,  should  be  the  treatment.     At  term,  forceps, 
version,  Caesarean  section  are  alternatives.     Alwaj^s  secure  a  consul- 
tation to  share  responsibility. 
Instruments  for  Operation. 

1.  Perforator.     Blot's,  Smellie  or  Hodge  scissors. 

2.  Large  catheter,  and  carbolized  solution  for  washing  out  brain 
substance. 


138  OBSTETRICAL  LECTURES. 

3.  Cephalotribe.     Karl  Braun's,  Tarnier's  Basiotribe. 

4,  Cranioclast.     Karl  Braun's  or  Hirst's. 

The  operation  consists  of  the  following  steps  : — 

(a)  Etherization. 

(b)  Vaginal  douche  of  bichloride  solution. 

(c)  Yolsella  forceps  to  steady  scalp. 
((^)  Perforation  of  cranium. 

(e)   Contents  of  cranium  washed  away. 

(/)  Crushing  with  cephalotribe. 

ig)  Extraction  with  cranioclast. 
Decapitation.  — 

Indication. — Impacted  shoulder  presentation. 
Instruments. — Braun's  hook,  or  Bamsbotham's  sharp  hook. 
Amputations.,  and  Evisceration  are  very  rarely  indicated.     Some 
forms  of  monsters  may  require  them. 

Symphyseotomy. 

The  operation  is  a  division  of  the  joint,  allowing  diastasis  of  the 
bones  during  labor,  the  child  being  delivered  by  the  natural  passage. 
Was  performed  for  the  first  time  on  a  dead  woman  in  1665,  on  a 
living  woman  in  1777.  In  1866  the  operation  was  revived,  and 
from  that  time  to  1881  it  was  performed  fifty-three  times  with  a 
death  rate  of  18  per  cent.  Not  much  space  is  gained  and  the 
operation  is  no  longer  employed. 

Caesarean  Section. 

When  the  escape  of  the  child  by  the  natural  passage  is  impossible, 
it  may  be  delivered  by  an  abdominal  and  uterine  incision  (Ceesarean 
section).  If  by  an  abdominal  and  vaginal  incision  the  operation 
is  called  laparo-elytrotomy.  Caesarean  section  may  be  performed 
ante-  or  jDOst-mortem. 

Post-mortem  Ccesarean  Section.  —When  the  death  of  the  mother 
is  assured,  cut  open  the  abdomen  and  uterus  with  any  instrument  at 
hand.  A  living  infant  has  been  extracted  twenty  minutes,  three  quar- 
ters of  an  hour  and  even  two  hours  after  the  death  of  the  mother. 

Ccesarean  Section  upon  the  Living  Woman. — Performed  for  the 
first  time  in  1500.  Five  years  ago,  in  England,  the  death  rate  was 
99 1^0  per  cent. 


OBSTETRIC   OPERATIONS.  1  ol> 

Varieties : — 

Porro-Ccesarean. — In  1876  Porro  modified  the  operation  by  per- 
forming, in  addition  to  laparo-hysterotomy,  a  laparo-hysterectomy, 
i  e.,  removal  of  the  uterus.  The  stump  is  fixed  in  the  abdominal 
wound  preferably  by  Koeberle's  noeud.  In  150  cases  the  death 
rate  was  54  per  cent.,  but  since  1884  to  the  present  time  it  has 
fallen  to  20  per  cent.  The  operation  is  performed  to  obviate  any 
discharge  into  the  abdominal  cavity  through  the  uterine  sutures. 

Porro- Milller. — In  this  a  long  abdominal  incision  is  made,  the 
uterus  is  lifted  out  and  then  incised.  The  application  of  an  Es- 
march  around  the  cervix  to  control  hemorrhage  was  also  a  modifica- 
tion of  Miiller. 

Sanger. — The  modifications  of  Sanger  have  given  an  operation 
which  is  the  most  successful  and  the  one  to  employ,  except  when 
certain  conditions  indicate  the  PoiTO-Caesarean  as  preferable.  The 
mortality  with  the  best  of  German  operators  is  5  per  cent.,  for 
mothers  and  less  for  the  children.  In  general,  it  has  now  been  re- 
duced to  20  per  cent.  ;  for  continental  Europe  to  12  per  cent.,  and 
there  have  been  six  consecutive  operations  in  Philadelphia  without 
a  death.  The  main  feature  of  Sanger's  discovery  is  the  introduc- 
tion of  two  rows  of  silk  sutures  to  close  the  uterine  incision,  one 
through  the  uterine  muscle  down  to  the  decidua  (two  to  the  inch), 
and  the  other  superficial  (Lembert  suture)  to  tuck  in  the  peritoneal 
covering  of  the  uterus  which  unites  in  twenty-four  hours,  and  thus 
prevents  leakage  into  peritoneal  cavity.  Another  element  of  success 
is  to  be  found  in  the  fact  that  the  operation  is  now  undertaken  in 
time,  before  forceps,  version,  embryotomy  or  other  operations  have 
been  tried. 

Indications. — Are  relative  and  absolute. 

(a)  Absolute. — Some  condition  which  admits  of  no  other  method 
of  treatment. 

1.  Pelvic  deformity.  In  flat  pelves  when  conjugata  vera  is  6.5 
cm.  (2J  inches)  or  less.  It  may  be  required  in  osteomalacia  and 
spondylolisthesis,  also  in  Nsegele'sand  Roberts'  pelves. 

2.  New  growths  obstructing  the  pelvis,  as  a  large  fibroid,  bony 
tumors  of  the  sacrum,  carcinoma,  etc. 

(h)  Eelative. — When  the  condition  admits  of  s(jme  other  method 
of  treatment,  but  the  question  arises  whether  Cesarean  section  will 


140  OBSTETRICAL  LECTURES. 

not  give  the  best  result  for  motlier  and  child,  i.  e. ,  it  is  selected  as 
likely  to  give  best  results. 

1.  Pelvic  deformity.  Conjugate  vera  6.5  cm.  {2^  inches)  to  8i 
cm.  (3^  inches).  When  the  conjugate  measures  83^  cm.,  the  opera- 
tion is  indicated  only  when  the  child  is  abnormally  large. 

2.  Rupture  of  the  uterus  may  often  require  the  Sanger  operation. 
The  Porro  operation  is  indicated  when  the  pelvis  is  so  choked  up 

as  to  interfere  with  drainage  of  lochia  ;  when  the  woman  has  been 
long  in  labor  and  is  septic,  or  when  other  methods  of  treatment 
have  been  unsuccessful,  and  the  danger  of  sepsis  thus  increased ; 
when  the  uterus  fails  to  contract,  or  when  hemorrhage  is  profuse. 

Technique  of  the  Operation. — (Sanger,  or  improved  Caesarean.) 

[a)  Time. — The  most  favorable  time  is  from  250th  to  265th  day 
after  conception.  The  introduction  of  a  bougie  into  the  uterine 
cavit}'^  to  institute  labor  pains  is  an  advantage.  The  operation  should 
be  performed  after  labor  has  begun. 

ih)  Instruments. — Those  ordinarily  used  in  a  laparotomy. 

(c)  Preparatory  Treatment. — ^Includes  disinfection  of  abdomen  and 
external  genitals,  evacuation  of  bladder  and  bowels,  etc.,  as  for 
laparotomy. 

(c?)  Abdominal  incision  should  extend  one-third  above  and  two- 
thirds  below  umbilicus. 

(e)  EsmarcTi  tiihe  should  be  placed  around  cervix  to  control  bleed- 
ing. 

(/)  The  uterine  incision  should  be  long  enough  to  allow  the  escape 
of  the  child's  head,  and  the  child  extracted,  grasping  it  as  may  be 
most  convenient. 

{g)  The  placenta  is  next  extracted.,  followed  by  the  Sanger  method 
of  suture  to  close  the  uterine  wound.  The  abdominal  wound  is  then 
closed  after  the  toilet  of  the  abdominal  cavity  has  been  completed,  and 
the  after-treatment  combines  the  features  of  management  after  labor 
and  laparotomy. 

Laparo-elytrotomy. 

In  ]  806  Jbrg  devised  an  operation  which  consisted  of  an  incision 
over  Poupart's  ligament,  dissecting  up  the  peritoneum  until  the  va- 
gina is  reached,  when  the  latter  is  incised  transversely,  the  cervix 
dilated,  and  the  child  thus  extracted  above  the  inlet.  In  1820  this 
operation  was  performed  by  Ritgen,  with  a  fatal  result.     In  1822  it 


DYSTOCIA.  141 

was  proposed  by  Physic,  of  Philadelphia,  and  in  1823  done  by  Bau- 
delocque.  In  1876,  Thomas  and  Skene,  of  New  York,  performed  it, 
and  it  was  called  by  them  laparo-elytrotomy.  Since  1876  its  mor- 
tality has  been  50  per  cent.,  and  therefore  it  shcjuld  not  come  into 
general  use. 

Laparo-cystectomy. 

An  operation  performed  in  advanced  extrauterine  pregnancy  for 
removal  of  foetus  and  entire  sac.  It  is  performed  like  an  abdominal 
section  for  any  cystic  tumor  in  the  abdominal  cavity  with  dense 
adhesions.  The  sac  is  to  be  evacuated  or  not,  as  indicat€d,  and 
adhesions  separated,  if  necessary,  after  ligation. 


Dystocia. 

Causes : — 

A.  Anomalies  in  force,  expulsive  or  resistant. 

B.  Accidents. 

C.  Disease. 

(A)  Anomalies  in  Force. 
/.   In  Expulsive  Power  of  Uterus  or  Abdominal  Muscles, 
(a)  Excess  of  expulsive  power. 
(h)  Defect  of  expulsive  power. 

(a)  Excess  of  Expulsive  Power. 

(1)  Uterine. — Excessive  uterine  contraction  is  rare.  Occurs  most 
frequently  in  primiparse,  and  does  not  seem  to  be  dependent  upon 
the  muscular  development  of  the  patient. 

Diagnosis. — iibdominal  palpation  shows  frequent  and  forcible 
uterine  contraction.  Vaginal  examination  shows  rapid  advance  of 
presenting  part.     Cry  of  patient  is  exaggerated. 

Difficulties. — The  severe  pain  and  precipitate  expulsion  of  the  child. 

Treatment. — Anaesthetic.  Resist  advance  of  presenting  part.  In 
the  earlier  stages  if  the  pains  be  so  fi-equent  as  to  threaten  exhaus- 
tion, lessen  nerve  action  and  muscular  power  by  chloral,  gr.  xv  every 
fifteen  minutes,  until  three  doses  are  taken.  Bromides  or  opium 
may  also  be  used. 

(2)  Abdominal — Excessive  abdominal  power  occurs  in  the  second 
stage,  and  should  be  similarly  treated. 


142  OBSTETRICAL  LECTURES. 

(3)  A  relative  excess  occurs  when  the  opposition  is  less,  as  in  a 
roomy  pelvis,  a  pelvis  with  straight  sacrum,  relaxed  or  lacerated 
perineum,  foetus  very  small  or  premature.  The  dangers  of  rapid 
expulsion  thus  likely  to  follow  are,  laceration  of  the  perineum,  syn- 
cope, post-partum  hemorrhage,  rupture  of  the  cord,  premature  de- 
tachment of  the  placenta.  When  due  to  such  a  cause,  treatment 
should  supply  resistance  by  holding  the  head  back  with  the  thumb 
or  small,  straight  forceps. 

(4)  Excess  occurs  when  there  is  a  gradual  decrease  of  the  intervals 
hetiveen  the  contractions^  until  a  final  condition  of  tetanic  spasm  may 
result.  This  may  be  due  to  a  serious  obstruction,  as  deformity  of 
pelvis,  abnormal  presentation,  fibroids,  cancer  of  cervix,  ovarian 
tumor,  agglutination  of  external  os,  etc.,  or  there  may  be  a  true 
spasm  of  the  utenis,  as  may  develop  in  an  irritable  primipara  with 
liquor  amnii  drained  ofi^. 

Diagnosis. — Bj^  palpation  above  and  below  the  contraction  ring. 
Treatment. — Remove  the  cause.      If  a  true  spasm,  chloral  and 
opium. 

(b)  Defect  of  Expulsive  Power. 

Uterine  Inertia — Causes. — (1)  Weakness  of  mu.scle.,  as  occurs  some- 
times in  multiparae,  exhausted  primiparae,  general  diseases,  as  pneu- 
monia, typhoid,  phthissis,  cancer,  over-distention  from  twins  or 
hydramnion. 

(2)  Ajyathy  of  muscle. 

(3)  Emotion. 

Dangers. — Relaxation  predisposes  to  septic  infection,  pressure 
necroses,  post-joartum  hemorrhage.  The  child  may  become  asphyx- 
iated by  pressure  on  its  brain  centres  or  compression  of  the  cord. 

Treat nient. — ^Rise  of  temperature  and  other  signs  of  exhaustion 
demand  interference.  It  is  always  best  to  err  on  the  safe  side  and 
terminate  the  labor.  If  due  to  weakness  of  muscle,  stimulants, 
quinine  gr.  xv,  forceps.  If  to  apathy  of  muscle,  introduce  a  bougie  ; 
if  to  emotion,  administer  an  anassthetic.  If  it  occurs  early,  termi- 
nate the  labor  by  rapid  dilatation  of  ceiTix  and'  version.  Ergot 
should  not  be  given,  as  it  excites  tetanic  spasm  and  contracts  the 
cervix.  The  foetus  is  often  semi-paralyzed,  its  blood  supply  partly 
shut  ofi",  and  if  an  obstmction  to  labor  exists,  rupture  of  the  uterus 
may  follow  its  use. 


DYSTOCIA.  143 

//   Anomalies  in  Force  of  Resistance. 

Maternal  Obstructions. 

1.  Contracted  Pelvis. 

Treatment. — Differs  with  grade  of  deformity.  Conjugate  9j  to 
11  cm. — Can  allcjw  to  go  to  term,  expecting  the  labor  to  be  rather 
difficult  and  prolonged.  Complicatifjns  are  frequent,  as  abnormal 
positions  and  presentations  of  child,  which  are  four  times  as  frequent 
as  in  normal  pelves.  Prolapse  of  cord  is  also  a  frequent  complication. 
The  most  frequent  abnormality  is  transverse  situatior  of  the  head  at 
pelvic  inlet,  as  described  under  abnormalities  in  the  mechanism  of 
vertex  presentations.  Prolongation  of  labor  and  exaggerated  com- 
plaints of  patient  must  be  expected.  Increased  expulsive  powers 
are  demanded,  and  if  insufficient,  forceps  or  version  must  be  resorted 
to.  In  primii3ara3  spontaneous  termination  is  more  frequent.  In 
multiparse,  or  when  muscular  force  is  diminished,  avssistance  is  often 
needed.  When  forces  are  normal  and  child  not  ovei'-sized,  non-inter- 
ference with  nature's  mechanism  is  the  cardinal  rale.  Forceps  inter- 
feres by  preventing  partial  extension,  favorable  moulding  and  lateral 
inclination,  and  should  not,  therefore,  as  a  nile,  be  applied  until  head 
has  entered  pelvic  cavity,  when  it  is  not  usually  required  unless 
inertia  uteri  develops.  Conjugate  heloic  9  to  9 J  cm. — Indicate  induc- 
tion of  premature  labor  from  2  to  4  weeks  before  expected  delivery 
depending  upon  degree  of  flattening.  After  labor  has  begun,  the 
head  in  flat  pelves  is  apparenth'  low  down,  from  shallow  depth 
of  pelvis  and  low  position  of  caput  succedaneum,  and  this  mis- 
taken idea  may  induce  one  to  apply  forceps.  In  such  a  case, 
either  non-interference  or  version  and  extraction  are  indicated, — 
the  former  in  primiparae  or  in  women  with  strong  expulsive  powers, 
the  latter  in  multiparas  or  in  women  with  deficient  expulsive  powers. 
Forceps  may  be  applied  after  the  head  has  entered  the  pelvLs.  Con- 
jugate so  contracted  as  to  he  impassahle. — Accurate  and  precise  diag- 
nosis of  the  degree  of  deformity  should  always  be  made  in  order  to 
spare  the  women  the  dangers  of  futile  attempts  at  extraction  with 
forceps  or  by  version,  when  craniotomy  or  Caesarean  section  are 
indicated.     (See  Craniotomy  and  Caesarean  section.) 

2.  Congenital  Anomalies  of  Development  in  Genital  Canal. — As 
double  uterus.     May  interfere  by  its  bulk  or   contractions  of  the 


144  OBSTETRICAL  LECTURES. 

empty  uterus.     If  placenta  is  attached  to  septum,  alarming  post- 
partum hemorrhage  may  occur. 

3.  Closin^e  and  Contraction  of  Cervix. — As  atresia.,  cicatricial 
contraction  or  rigidity.  Atresia  is  never  complete,  and  may  be  over- 
come by  pressure  on  the  small  opening  with  the  tip  of  a  sound  or 
finger.  Cicatricial  contraction  may  require  incisions,  controlhng  the 
hemorrhage  temporarily  by  clamped  sutures.  Rigidity  usually  yields 
to  copious  hot  douches.  Chloral,  morphia,  belladonna  ointment 
have  been  recommended. 

4.  Closure  and  Contraction  of  Vagina  or  Vulva. — As  by.  con- 
stricting bands,  cicatrization,  haematomata,  requiring  incisions. 

5.  Displacements  of  Uterus. — Anterior,  lateral,  sacculation,  hyper- 
trophic elongation  of  cervix.  The  first  requires  a  binder,  the  second 
side  position,  with  compress  under  fundus.  Version  or  forceps  to 
bring  head  into  pelvic  cavity  for  sacculation.  Incisions  radiating 
from  OS  for  elongated  cervix. 

6.  Tumors  of  Genital  Canal.  —  Carcinoma  of  Cervix. — If  exten- 
sive may  require  Caesarean  section. 

Fibroids. — If  low  down  and  diagnosed  during  pregnancy,  remove 
by  abdominal  section,  induce  abortion,  or  perform  Csesarean  section  at 
term.    If  movable  they  maj^^  be  pushed  out  of  the  way  during  labor. 

Polypi. — Ligate  base  and  remove  at  term. 

7.  Tmnors  of  Neigliboring  Organs.  —  Ovarian  Cystoma. — Usu- 
ally cause  abortion.  Ovariotomy  during  pregnancy  is  justifiable.  If 
they  obstruct  during  labor  aspirate  per  vaginam.  Cysto-colpocele 
or  Rectocele  should  be  replaced  until  forceps  are  used  to  bring  the 
head  past  them.  Calculi  or  fecal  masses  should  be  removed.  A 
decomposed  foetus  in  utero,  as  result  of  obstructed  labor,  should  be 
removed  antiseptically. 

FcETAL  Obstructions. 

1.  Overgroictli. 

2.  Malformations  and  Tumors. — Treatment  varies  with  each 
case.     Version  or  embryotomy  usually  required. 

3.  Diseases.  — As  cystic  kidneys,  eifusions  into  the  serous  cavities, 
anasarca,  enlarged  liver,  etc. 

4.  Malpresentations  and  Faulty  Positions. — As  shoulder,  face, 
brow,  compound. 


DYSTOCIA.  145 

5.  Multiple  Birtlis. 

Twins. — Head  of  one,  feet  of  the  other,  most  frequently  present. 
If  both  engage,  retard  one  and  extract  the  other.  The  cord  may  be 
coiled  around  one.  The  chins  may  lock,  when  an  effort  should  be 
made  to  push  back  the  one  presenting  by  the  head.  Failing,  ampu- 
tate the  head  of  this  one  and  deliver  the  one  presenting  by  the 
breech,  or  push  the  latter  back  and  deliver  the  fonner  with  forceps. 
In  any  case,  when  one  is  born,  do  not  follow  the  expectant  plan,  as 
sometimes  advised,  but  at  once  determine  the  position  and  presenta- 
tion of  the  one  remaining  in  utero.  Correct  it,  if  necessary  ;  give 
ergot  and  terminate  the  labor. 

6.  Abnormalities  in  Foetal  Appendages. 

Membranes. — If  too  thin,  an  early  rupture  precedes  a  dry  labor 
with  irritable  uterus  ;  if  too  thick,  child  apt  to  be  born  with  a 
"caul."  Liquor  Amnu. — If  too  little,  consequences  are  similar  to 
those  of  premature  rupture  ;  if  too  much,  there  is  inertia,  as  result  of 
over-stretching. 

Cord. — If  short,  may  cause  premature  detax^hment  of  placenta 
or  prevent  advance  of  the  child. 

Placenta.. — May  be  adherent,  from  syphilis  or  endometritis  during 
pregnancy.  The  alarming  hemorrhage  resulting  requires  removal  of 
the  adherent  portion. 

(B)  Dystocia  due  to  Accidents  to  Child  or  Mother. 

{a)  Accidents  to  the  Child. — 1.  Prolapse  of  Cord.  Causes  : 
lack  of  conformity  of  presenting  part  with  shape  and  size  of  pelvis, 
as  small  head,  malpresentations  (face,  shoulder,  breech),  contracted 
pelvis.  Less  commonly  hydramnios,  too  long  a  cord,  lateral  devia- 
tion of  uterus. 

Diagnosis. — Easy.     Has  been  mistaken  for  prolapse  of  intestines. 

Prognosis. — Mortality  53  per  cent. 

Treatment. — Postural  and  manual,  i.  e. ,  knee-chest  posture,  and 
endeavor  to  replace  with  fingers.  Instrumental,  a  catheter  with 
counter-opening  used  as  repositor.  If  these  fail,  resort  to  version  or 
rapid  extraction  with  forceps,  placing  the  cord  at  that  sacro-iliac  joint 
where  it  would  be  least  pressed  upon. 

2,  Rupture  of  Cord.    Rare. 

(h)  Accidents  to  the  Mother. — Hemorrhage  occurring  before, 
10 


146  OBSTETRICAL   LECTURES. 

during  or  after  labor.     Ante-partuiji  hemorrhage  may  be  due  to  pla- 
centa praevia,  premature  detachment  of  placenta,  rupture  of  uterus. 

(1)  Placenta  Prcevia. — The  placenta  is  said  to  be  praevia  when  it 
is  attached  to  anj^  portion  of  the  lower  uterine  segment. 

Causes. — It  is  the  result  of  a  low  situation  of  the  ovum,  but  why 
this  occurs  is  not  yet  satisfactorily  explained.  It  is  more  frequent 
in  multipar^e  and  those  of  the  poorer  class. 

Varieties. — Central,  Partial,  Marginal,  Lateral. 

Symptoms. — Hemorrhage,  occurring  as  early  as  the  second 
month  in  the  central  variety,  during  labor  or  not  at  all  in  the  lateral. 
The  characterivStics  ol  the  hemorrhage  are,  sudden  onset  without 
pain,  the  ])atient  often  finding  a  gush  of  blood  while  in  bed,  and 
return  of  tlie  bleeding,  with  progressively  increasing  quantity  at  de- 
creasing intervals.  Rarely,  the  hemorrhage  is  controlled  by  nature, 
a  clot  forming  or  syncope  occurring,  and  a  fatal  hemoiThage  before 
the  7th  month  has  not  been  recorded. 

Treatment. — Prior  to  7th  month,  expectant.  After  7th  month, 
mduction  of  premature  labor  by  forced  dilatation  of  cervix  and  com- 
bined version.  The  breech  should  be  brought  down,  as  it  controls 
the  hemorrhage  and  does  not  cut  off  the  blood  supply  to  the 
foetus.  Use  the  right  hand  internally,  as  the  smallest  segment  of 
the  placenta  is  usuall}^  on  the  left  side. 

In  the  central  variety  perforate  the  placenta  if  necessaiy. 

Wiegand's  treatment  is  placing  an  antiseptic  tampon  in  the  upper 
third  of  the  vagina,  allowing  the  head  to  push  it  out. 

Incubation  and  gavage  should  be  used  if  the  child  is  born  early 
after  7th  month. 

(2)  Accidental  Hemorrhage. — Hemorrhage  from  premature  de- 
tachment of  the  placenta.     May  be  one  of  four  classes  : — 

1.  Centre  of  placenta  detached. 

2.  Upper  margin  detached  and  blood  extravasated  between  mem- 
branes and  uterus. 

3.  Membranes  rupture  and  blood  passes  into  amniotic  cavity. 

4.  Cervix  obstmcted  by  clot,  membranes  or  presenting  part,  when 
it  is  concecded. 

Causes. — Similar  to  those  of  abortion,  as  decidual  apoplexy, 
violent  exercise,  emotion,  etc.  Occurs  more  frequently  in  the  latter 
months  of  pregnane}^  and  in  multiparae. 


DYSTOCIA.  147 

Diagnosis.— The  symptoms  are  similar  to  rapture  of  utemp. 
There  is  hemon-hage,  with  sudden  excraciating  pain  and  shock  in 
both,  but  in  rupture  of  the  uteras  the  membranes  are  broken,  the 
presenting  part  recedes,  the  uteras  is  well  contracted,  while  in 
accidental  hemorrhage  the  membranes  are  not  always  broken,  the 
presenting  part  does  not  recede  and  the  uteras  is  distended  by  the 
accumulated  blood,  particularly  in  the  concealed  variety. 

Progjiosis.  — Grave. 

Treatment. — Perforate  membranes,  thus  securing  some  control  of 
hemorrhage  by  the  contraction  of  uteras,  fVjllowed  by  forced  dilata- 
tion of  cervix  and  version. 

(3)  Post-Partum  ^e^norr/ior/e.— Nature's  mechanism  of  controlling 
hemorrhage  : — 

1.  Leucocytes  beginning  to  block  up  sinuses  in  latter  months  of 
pregnancy. 

^.  Contraction. 

3.  Retraction. 

Cau,ses : — 

1.  Those  which  interfere  vnth  crmtraction,  as  {a)  weakness 
from  general  disease,  bad  hygiene,  mental  anxiety  ;  {h)  muscle  fibre 
at  fault,  as  when  undeveloped,  fatigued,  overstretched,  or  inactive 
by  reason  of  surrounding  inflammatory  products  ;  (c)  anomalies  in 
innervation  of  muscle  fibre. 

2.  Mechanical— Rttmnecl  placenta,  clots,  old  adhesions,  tumors, 
as  fibroids,  ovarian  cysts,  distended  bladder  or  rectum. 

Symptoms.— ^uMen  gush  of  blood,  or  four  or  five  ounces  lost 
eveiy  few  seconds.  Uteras  relaxed.  Constitutional  signs  of  severe 
hemorrhage,  as,  vertigo,  air  hunger,  pallor,  etc. 

Treatment.— {a)  Propliylactic.  When  there  is  any  probability  of 
its  occurrence,  as  soon  as  head  is  born  inject  into  thigh  a  syringefal 
of  ergot,  properly  manipulate  uteras  and  apply  binder. 

(b)  Curative. — Always  have  in  readiness,  water  1 12°-120°,  empty 
basin,  vinegar,  ice  broken  size  of  fist,  clean  handkerchief,  hypoder- 
mic syringe,  ergot. 

The  indications  are  :  1.  Control  the  hemorrhage,  and  2,  treat  the 
after  condition. 

The  first  indication  is  met  by  the  following  in  the  order  given  : — 

(a)  External  stimulation  of  uterus. 


148  OBSTETRICAL  LECTURES. 

(b)  Cany  the  other  hand  into  the  uterus  and  remove  any  clots, 
placenta,  etc. 

(c)  Ice  applied  internally  and  externally,  but  not  persisted  in. 

(d)  Handkerchief  soaked  in  vinegar  squeezed  at  the  fandus. 

(e)  Hot  water. 
(/)  Electricity. 

ig)  Intrauterine  tampon  of  iodoform  gauze. 

(h)  Drugs,  as  iodine,  styi:)tic  salts  of  iron,  etc.,  are  dangerous, 
as  the  coagula  produced  by  them  may  extend  into  the  vessels,  are 
firm  and  must  be  broken  up  by  putrefaction,  exposing  the  patient  to 
septic  poisoning. 

Treatment  of  the  After-condition. — While  controlling  the  hemor- 
rhage, nurse  should  administer  hypodermic  of  ether.  When  the 
bleeding  has  ceased  administer  an  enema  of  hot  water  and  fre- 
quently repeated  small  doses  of  coffee,  milk,  brandy,  etc.  Auto- 
transfusion  by  bandaging  extremities,  compressing  abdominal  aorta 
or  actual  transfusion  {^jj  of  1  per  cent,  of  ordinary  NaCl  solution). 
When  reaction  is  established,  a  hypodermic  of  morphia  may  be 
given. 

(4)  Hemon-Tiagefrom  Injuries.  — Exceptionally  may  be  fatal.  The 
most  common  source  is  in  the  anterior  wall  of  vagina  near  the 
urethra,  where  it  should  be  controlled  by  antiseptic  catgut  or  silk 
ligature.  Exceptionally  an  anomalous  artery  may  be  torn  in  the 
cervix  or  perineum  requiring  immediate  operation. 

(5)  Rupture  of  Uterus. 
Cause. — Obstruction  to  labor. 

Diagnosis. — Placenta  Prgevia,  Accidental  Hemorrhage,  Rupture 
of  Uterus  are  the  three  causes  of  grave  antepartum  hemorrhage.  In 
the  latter  there  is  shock,  great  alarm  on  the  part  of  the  patient,  the 
membranes  are  broken,  the  presenting  part  recedes,  the  examining 
hand  finds  the  rent,  and  perhaps  feels  coils  of  intestines.  The  child 
may  be  felt  in  the  abdominal  cavity  with  the  uterus  small  and  firmly 
contracted.  The  danger  signal  is  thinning  of  the  lower  uterine  seg- 
ment and  a  high  position  of  the  contraction  ring. 

Treatment. — Varies  with  the  cause.  Deliver  by  podalic  version. 
If  the  hemorrhage  ceases  and  there  are  no  clots,  no  meconium  and 
good  drainage,  no  active  treatment  required  beyond  irrigation  with 
2  per  cent,  solution  of  creolin,  otherwise  open  abdomen  and  suture 


DYSTOCIA.  .  1 49 

after  the  Sanger  method.  During  the  puerperium  the  uterus  may- 
rupture  as  result  of  septic  ulceration,  pressure  necroses,  or  more 
rarelj^  from  malignant  septic  degeneration  of  the  chorion. 

(6)  Inversion  of  the  Uterus — The  rarest  of  all  accidents  to  the 
mother,  and  happens  before  or  after  delivery  of  the  placenta  with 
equal  frequency.     It  may  be  partial  or  complete. 

Cause. — It  may  arise  spontaneously  in  the  so-called  paralysis  of  the 
placental  site,  or  it  may  be  due  to  too  vigorous  traction  on  the  cord 
or  compression  of  the  fundus. 

Symptoms. — Occurs  suddenly  and  is  usuallj^  associated  with 
shock  and  hemorrhage.  Physical  exammation  per  rectum  reveals 
a  cup-like  body  containing,  perhaps,  the  prolapsed  tubes  and  ovaries. 

Treatment. — Occasionally  spontaneous  reduction  occurs,  particu- 
larly when  the  inversion  is  partial.  Remove  the  placenta  if  still 
adherent  and  reduce  as  Lusk  advises,  or  by  placing  fingers  just  inside 
the  constricting  cei"vix,  and  while  spreading  apart  to  relieve  constric- 
tion the  thumb  pushes  fandus  up. 

(7)  Other  accidents  to  the  mother  are  Rupture  of  Symphysis.,  re- 
quiring a  binder  or  plaster  bandage  ;  Separation  of  Sacro-iliac 
Joints;  Fracture  of  Sacro-coccygeal  Joint ;  JjCicerations  and  Per- 
forations icith  Instruments ;  Diastasis  of  Ahdominal  Muscles. 

(C)  Dystocia  due  to  Disease. 

(1)  Puerperal  Convulsions. —  Causes.  —  Hysteria,  epilepsy,  tumors 
of  the  brain,  meningitis,  profound  anaemia  following  post-partum 
hemorrhage,  apoplexy,  or  the  convulsions  may  arise  in  that  curious 
nervous  condition  after  labor  or  during  pregnancy  so  easily  respond- 
ing to  reflex  disturbances. 

(2)  Eclampsia. — Is  the  name  given  to  the  most  frequent  variety 
of  puerperal  convulsions. 

Causes. — Obscure.  Theories  of  causation  :  (a)  Urea.  (Jj)  Car- 
bonate of  Ammonium,  (c)  Uringemia.  id)  Trauber-Rosenstein. 
(e)  Prof  Hirst  approves  the  following  :  Angemia  in  the  deeper  por- 
tions and  congestion  of  the  surface  of  the  brain,  due  to  the  sudden 
rise  of  arterial  pressure  resulting  from  the  accumulation  of  poisons 
in  the  mother's  blood  (probably  leucomaines  generated  in  the  foetal 
body),  her  kidneys  being  unable  to  excrete  them.  Insufficient  ex- 
cretion may  be  produced  by  occlusion  of  ureters. 


150  OBSTETRICAL  LECTURES. 

Frequency. — Occurs  once  in  three  hundred  cases;  most  frequently  in 
primiparse,  and  during  labor  ;  least  frequently  duringthe  puerperium. 

Symjjtoms. — (a)  Prodromal. — Sharp  pain  is  sometimes  felt  in  the 
head,  epigastrium  or  under  clavicle  ;  muscae  volitantes  with  failure 
of  vision  and  rolling  of  the  head. 

(h)  Of  the  Attack. — A  few  moments  after  the  above  the  attack 
comes  on  with  a  stare,  pupils  at  first  contract,  eyelids  twitch,  eye- 
balls roll,  mouth  pulled  to  one  side,  the  neck  is  then  afi'ected,  and 
the  spasm  finally  spreads  to  trunk  and  upper  extremities.  The 
lower  part  of  lower  extremities  are  rarely  spasmodically  affected. 
Consciousness  is  lost  for  a  minute  or  two,  and  during  the  varying 
length  of  interval  between  the  attacks  there  is  more  or  less  stupor. 

Prognom. — 30  per  cent.  die.  Influenced  by  the  violence  and  fre- 
quency of  the  attacks,  the  character  of  the  pulse,  degree  of  coma, 
and  perhaps  the  height  of  temperature.  Mortahty  of  the  child,  50 
per  cent. 

Treatment.— [a)  Preventive. — The  urine  of  all  pregnant  women 
should  be  critically  examined.  If  there  be  evidences  of  nephritis  or 
the  kidney  of  pregnancy,  a  restricted  diet  consisting  largely  of  milk 
should  be  advised.  Colds  should  be  avoided,  diuretics  administered, 
and  cathartics  to  prevent  constipation.  If  the  symptoms  fail  to 
respond  to  this  treatment,  the  induction  of  premature  labor  should 
be  considered. 

(Jb)  Curative. — Indications  are  to  eliminate  the  poison  and  combat 
the  spasm.  Includes  the  treatment  of  the  spasm  during  the  inter- 
vals, and  the  obstetric  treatment.  During  the  spasms,  inhalations 
of  chloroform.  In  the  interval  between  the  spasms,  venesection,  a 
pint  or  more  ;  croton  oil,  two  or  three  drops  ;  an  enema  containing  a 
drachm  of  the  bromide  of  potash  and  forty  grains  of  chloral.  In 
severe  cases,  a  hot  bath,  100°  or  more,  with  ice  or  cold  cloths  applied 
to  the  head.  Morphia,  elaterium,  veratrum  viride,  may  be  used. 
Gruard  the  patient  from  injury,  especially  the  tongue,  which  may  be 
protected  by  placing  between  the  teeth  a  brush  handle  wrapped  in 
a  handkerchief. 

1.  Obstetric  Treatment. — If  the  os  is  dilated,  terminate  the  labor 
with  forceps  or  by  version.  If  the  convulsions  occur  early,  and  the 
OS  is  not  dilated,  wait  until  partial  dilatation  occurs,  and  complete 
the  delivery  by  combined  version  and  extraction. 


DYSTOCIA.  151 

2.  Shock. — Lowered  temperature  and  other  symptoms  of  shock 
may  develo])  after  kibor. 

3.  Typhoid. — Rare.  Premature  labor  occurs  in  65  per  cent,  of 
cases. 

4.  Pnetononia  or  otJter  Adynamic  Diseases. — Require  stimulants. 
Whiskey,  digitalis,  carbonate  of  ammonium  administered  in  the  first 
stage  and  labor  terminated. 

5.  Vahular  Defect  in  Heart. — Extensive  mitral  disease  fre- 
quently causes  death.  The  heart  is  embarrassed  during  pregnancy 
or  labor,  and  manifests  its  weakness  directly  after  the  expulsion  of 
the  child  or  placenta.  When  the  discharge  of  blood  is  profuse,  car- 
diac failure  is  rare  in  these  cases,  thus  indicating  the  treatment  : 
Venesection,  removing  8-16  oz. ,  if  there  is  not  much  blood  lost  after 
labor.  Digitalis  should  be  given  in  the  first  stage,  and  forceps  or 
version  and  extraction  resorted  to  in  the  second. 

Sudden  Death  during  or  directly  after  Labor. 
Causes. — 1.  Pr< found  Mental  Impressions.,  as  sudden  joy,  grief, 
fear,  exaggerated  shame. 

2.  Thrombosis,  resulting  from  excessive  pains. 

3.  Heart  failure,  most  frequently  due  to  fatty  degeneration. 

4.  Some  Complications,  as  accidental,  unavoidable,  or  post-partum 
hemorrhage,  ruptiu^e  or  inversion  of  uterus. 

5.  Rupture  of  Hcematoma,  externally  or  internally. 

6.  Syncope. — This  is  not  usually  fatal.  It  is  favored  by  the  deter- 
mination of  blood  from  the  brain,  as  by  hemorrhage.  Thromboses 
in  the  heart  may  form,  and  those  in  the  uterine  sinuses  may  be  pro- 
longed and  embolism  result. 

7.  Embolus. — Maybe  the  result  of  syncope,  or  it  may  be  caused 
by  entrance  of  air. 

Symptoms. — Sudden  shock,  heart  failure,  death. 

8.  Ruxjture  of  Gastric  Ulcer. 

Effect  of  Maternal  Death  upon  the  Foetus. — The  foetus  sui-vives 
rarely  more  than  a  few  minutes.  It  has  lived  for  two  hours.  When 
making  an  autopsy  on  a  jjarturient  woman,  it  is  convenient  to  split 
the  symphysis  and  remove  the  genital  tract  in  one  piece. 


APPENDIX. 


Selection  of  Wet  Nurse. 

In  addition  to  qualities  enumerated  (page  45),  she  should,  pre- 
ferably, be  a  multipara ;  her  child  approximately  the  same  age  as 
the  one  to  be  nursed ;  nipple  should  be  well  shaped,  and  it  is  of 
advantage  to  have  made  a  chemical  analysis  of  her  milk. 


Artificial  Feeding. 

The  disadvantages  of  substituting  cows'  for  mother' s  milk  may  be 
accounted  for  by  three  factors  : — 

1.  Difference  in  Chemical  Composition  (see  Table  of  Analysis, 
page  44). — This  difficulty  is  overcome  by  preparing  the  milk  as  fol- 
lows :  To  make  four  ounces,  take  3  tablespoon  fuls  of  weak  cream 
or  2  of  ordinary  cream  and  1  tablespoonfal  of  milk,  4  tablespoonfiils 
of  sterilized  water,  1  tablespoonfal  of  lime-water,  102  grains  of  sugar 
of  milk. 

2.  Bacteriological  Contents. — Cows'  milk,  particularly  in  the  hot 
summer  months,  is  infected  with  microorganisms  and  theu-  poisonous 
products,  ptomaines.  Tyrotoxicon  is  the  most  viralent  animal  alka- 
loid found  in  milk.  To  destroy  these  poisons,  sterilization  by  steam 
is  necessary.  Boiling  changes  the  chemical  constitution  and  renders 
the  milk  less  nutritious  (3  per  cent,  of  CO 2,  oxygen,  nitrogen  driven 
ofi",  and  20  per  cent,  of  albuminoid  constituents  found  as  a  thick 
scum  on  the  surface).  Two  steamings  for  twenty  minutes  each  will 
absolutely  sterilize  the  milk ;  one  is  usually  sufficient. 

3.  Quantity. — Overfeeding  is  a  common  mistake.  The  following- 
table  indicates  the  proper  quantity : — 

11  153 


154 


APPENDIX. 


Age. 

Interval. 

Number  of 

Feedings  in  24 

Hours. 

Amount  of 

Food  at 

Each  Feeding 

Total 

Amount  in 

24  Hours. 

1st  week. 

2  hours. 

10 

1  oz. 

10 

2d-6th  week. 

23^  hours. 

8 

1-2 

12-16 

6th-12th  week. 

3  hours. 

6 

3-4 

18-24 

6th  month. 

3  hours. 

6 

6 

30 

12th  month. 

3  hours. 

5 

8 

40 

The  greater  the  weight,  the  greater  the  gastric  capacity.  Grastric 
capacity  =  x^  of  body  weight  +  1  grarame  each  day  (Ssnitkin).  It 
takes  a  baby  fifteen  minutes  to  empty  the  breast,  and  this  time, 
therefore,  should  be  consumed  in  emptying  the  bottle.  The  plain 
rubber  nipple  should  be  used,  not  the  feeding  tube. 

Preparation  of  Artificial  Food. — 1.  Have  ten  small  Rotch  bottles 
prepared  clean  every  morning. 

2.  Put  in  each  of  them,  by  means  of  a  funnel,  to  secure  dryness 
of  the  neck  of  the  bottle,  cream  5iv,  milk  5ij,  water  ^j,  milk  sugar 
gr.  1. 

3.  Steiilize. 

4.  Add  5ij  lime-water  to  each  bottle  before  use. 

This  mixture  lacks  by  3^  of  1  per  cent,  the  same  amount  of  non- 
coagulable  albuminoids  as  compared  with  mother's  milk.  Should 
the  chUd,  by  weekly  weighings,  fail  to  show  the  normal  gain,  add 
one  and  a  fourth  drachms  of  white  of  egg  to  ten  ounces  of  water, 
and  distribute  this  among  the  ten  bottles. 

Proprietary  foods  should  not  be  used.  Condensed  milk,  under 
some  circumstances,  may  be  employed,  diluted  with  nine  parts  of 
water,  and  3j  cream  added  for  each  ounce. 


DATE  DUE 

M/IR2  5  7m 

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18 

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Demco,  Inc.  38-293 

COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RG  533  .N67  1890  C.1 

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